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Full text of "U.S. Navy Medicine Volume 69, Number 4 April 1978"

VADM Willard P. Arentzen, MC, USN 

Surgeon General of the Navy 

RADM R.G.W. Williams, Jr., MC, USN 

Deputy Surgeon General 



MANAGING EDITOR 

Ellen Casselberry 

ASSISTANT EDITOR 

Virginia M. Novinski 

EDITORIAL ASSISTANT 

Nancy R. Keesee 

CONTRIBUTING EDITORS 

Contributing Editor-in-Chief: 
CDR C.T, Cloutier (MC) 
Aerospace Medicine: CAPT M.G. Webb 
(MC); Dental Corps: CAPTR.D. Ulrey (DC); 
Education: CAPT S.J. Kreider (MC); Fleet 
Support: LCDR J.D. Schweitzer (MSC); 
Gastroenterology: CAPT D.O. Castell 
(MC); Hospital Corps: HMCM H.A. 
Olszak: Legal: LCDR R.E. Broach 
(JAGC): Marine Corps: CAPT D.R. Hauler 
(MC); Medical Ser\-ke Corps: CDR R.L. 
Surface (MSC); Naval Resent: CAPT J.N. 
Rizzi (MC, USN); Nephrology: CDR J.D. 
Wallin (MC); Nurse Corps: CAPT P.J. 
Elsass (NO; Occupational Medicine: CAPT 
G.M. Lawton (MC); Preventive Medicine: 
CAPT D.F. Hoeffler (MC); Psvchiatty: 
CAPT S.J. Kreider (MC): Research: CAPT 
J. P. BSoom (MC); Submarine Medicine: 
CAPT J.C. Rivera (MC) 

POLICY: U.S. Navy Medicine is an official publication 
of the Navy Medical Department, published by the Bureau 
of Medicine and Surgery, li disseminates to Navy Medical 
Department personnel official and professional information 
relative lo medicine, dentistry, and the allied health sci- 
ences. Opinions expressed are those of the authors and do 
rot necessarily represent the official position of the Depart- 
merit of the Navy, the Bureau of Medicine and Surgery, or 
any other governmental department or agency. Trade 
names are used for identification only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medicine and Surgery- Although V. £ Navy Medi- 
cine may cite or extract from directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION: U.S. Navy Medicine is distributed to 
active-duty Medical Department perscnncl via the Standard 
Navy Distribution List. The following distribution is author- 
ized: one copy for each Medical, Dental. Medical Sen-ice 
and Nurse Corps officer; one copy for every 10 enlisted 
Medical Department members. Requests to increase or de- 
crease the number of allotted copies should be forwarded to 
U.S. Navy Medicine via the local command. 

CORRESPONDENCE: All correspondence should be 
addressed lo: Editor, U.S. Navy Medicine. Department of 
the Navy, Bureau of Medicine and Surgery (Code 0010), 
Washington. D.C. 20372, Telephone: (Area Code 202) 
254-4253. 254.-4316, 254-4214: Autcvon 294-4253. 294-4316. 
294-4214, Contributions from the field arc welcome and will 
be published as space permits, subject to editing and pos- 
sible abridgment. 

The issuance of this publication is approved in accor 
dance with Department of the Navy Publications and 
Printing Regulations (NAVEXOS P-35). 



NAVMED P-S088 



U.S.NAVY 




Volume 69, Number 4 
April 1978 



1 From the Surgeon General 

2 Department Rounds 

Reaching Out at Midway Island 
LCDR S.M. Krenytzky, MC, USNR 

4 Nephrology Progress at NRMC Oakland 

5 Notes and Announcements 

In Memoriam . . . Surgical Pathology Course Set for June . . , Den- 
tal Correspondence Course Revised . . . Medical Film and Videotape 
Catalog Updated . . . New Organization for Navy Emergency Medi- 
cine Physicians 

7 On Duty Dental Technician: A Life with Goals — and Rewards 

8 Features 

Medical Records — Good and Bad 
D.C. Rasinski, M.D., J.D. 

15 Policy 

Use of Ethylene Oxide in Hospitals 
CDR J.P. Swope, MC, USN 

16 Scholars' Scuttlebutt ACDUTRA at OIS Newport 

18 Highlights NOTAP Corpsman Rating Study Under Way 

19 Letters 

20 Education and Training 

AFRRI/NNMC Nuclear Weapons Effects Course 
CDR R.F. Kiepfer, MC, USN 
LTC J.T. Mason III, USA 
LTCOL LF. Winans, USAF 

23 Professional 

A Report of Intractable Epistaxis 
CDR A.D. Kornblut, MC, USNR 
CDR R.A. Kempf, MC, USN 
LCDR F.S. Curto, Jr., MC, USN 

26 Survey of Tarsal Coalitions Found at MCRD Parris Island, S.C. 
LT J.J. Malone, MSC, USN 

29 BUMED SITREP 

COVER: DT2 Mark Roberson — assigned to the Base Dental Clinic, 
Marine Corps Logistics Support Base, Barstow, Calif. — puts finishing 
touches on a set of dentures. This month the Navy's dental technicians 
are celebrating the 30th anniversary of their rating. For a sample of 
their "on duty" world, see page 7. (Photo by J.J. Amari) 



From the Surgeon General 



Thirty Years of Service 



In April, the Navy Dental Techni- 
cian Rating celebrates its 30th Anni- 
versary. Over the years, many chal- 
lenges have been offered and met 
by Navy dental technicians. The 
manner in which they have met 
these challenges, their "can do" 
spirit, and their devotion to duty 
have earned them the respect of all 
with whom they have served. In 
duty stations throughout the world, 
Navy and Marine Corps personnel 
have benefited from the training, 
experience and competent perform- 
ance of this dedicated group of men 
and women. 

As an integral part of the health 
care system, dental technicians pro- 
vide a wide variety of services in 
support of the delivery of dental 
care. The services rendered by 
dental assistants can vary from 
direct patient care to performing 
maintenance on dental equipment. 
Whatever the task may be, Navy 
dental technicians are trained to as- 
sist dental officers in providing the 
best dental care available through- 
out the world. At the same time 
there has been a real team spirit 
and a sense of determination to 
achieve this goal. 

The success of dental regional iza- 
tion has exceeded our expectations. 
Clinical procedures have increased; 
control and management of re- 
sources have improved; the level of 
dental disease has been reduced; a 




VADM Arentzen 

greater degree of patient satisfac- 
tion has been noted; line command- 
ing officers have acknowledged and 
confirmed their acceptance of the 
system; and, most importantly, the 
operational readiness posture of our 
naval forces has been heightened by 
the improvement in the level of 
dental health of Navy and Marine 
Corps personnel . The state of dental 
health of our active forces has never 
been higher. 

Needless to say, as Surgeon 
General, I am delighted over this 
progressive management approach. 



This approach is integral with and 
complementary to our comprehen- 
sive program for total health care 
for our men and women in the Navy 
and Marine Corps. 

For the dental technicians, the 
future holds a multitude of chal- 
lenges. To meet these challenges 
and to seize upon the opportunities 
available, continuing education is a 
must. The Medical Department de- 
pends on the energy, desire and 
skill of all our members to fulfill our 
mission. It has been through those 
efforts that we have been able to 
achieve what we have today, and it 
will take even greater efforts to 
make our system better in the 
future. We must provide a person- 
ally stimulating and rewarding pro- 
fessional experience. In such a cir- 
cumstance, delivery of the highest 
quality dental care is inevitable — 
just as it is in all health care activi- 
ties. 

Navy dental technicians can be 
assured of the Medical Depart- 
ment's full support. Together we 
can meet any new challenges that 
lie ahead. 



ji./fc 




W.P. ARENTZEN 

Vice Admiral, Medical Corps 

United States Navy 



Volume 69, April 1978 



Department Rounds 



Naval Hospital Quantico 



Reaching Out at Midway Island 



LCDR S. Marc Krenytzky, MC, USNR 



An outreach program believed to 
be unique in Navy medicine is 
bringing health care to a small, iso- 
lated community of military families 
near Quantico, Va. 

The greatest portion of the Ma- 
rine Corps Development and Educa- 
tion Command lies in Virginia's 
Prince William County, a highly 
populated suburban area. But the 
Command's southernmost portion 
protrudes into Stafford County, a 
sparsely populated rural commu- 
nity. Within the area of this protru- 
sion lies Midway Island — a com- 
munity of 236 military family dwell- 
ings geographically isolated from 
the main base. The houses are 
small, adjudged substandard, and 
available only to married enlisted 
military personnel in the ranks of 
E-3 and below. The housing is avail- 
able at lower cost than standard 
quarters and is assigned primarily 
to people not eligible to live on 
base. 

Lonely lifestyle. Predictably, in 
this isolated junior enlisted popula- 
tion there is a multitude of social, 
emotional, and medical problems. 
Life at Midway Island can be diffi- 
cult: the residents are young, some- 
times newly married, and separated 
for the first time from their parents 
(many of the residents are new par- 
ents themselves); only 5% of the 
houses have telephones; the hus- 
band goes to work in the family's 
only car, leaving his young wife 



From the Pediatric Service, Naval Hos- 
pital, Quantico, Va. 22314. 

Dr. Krenytzky is in the private practice of 
pediatrics, in Manassas, Va. 




Volunteer provides play therapy for 
children (above); nurse practitioner ex- 
amines infant with mother's help (right) 

without transportation or compan- 
ionship; and lack of money means 
there is little relief from a lonely and 
drab lifestyle. 

These problems did not escape 
the attention of six military wives — 
all registered nurses — who lived on 
Midway Island and wanted to help 
their neighbors. They won the back- 
ing of Naval Hospital Quantico, and 
in January 1976 the Midway Island 
Community Health Center was es- 
tablished. 

The Health Center uses one of 
two small, general purpose rooms in 
the Midway Island Community Ac- 
tivities Center. Although it is run 




U.S. Navy Medicine 




LT Lynn Blackwood (MSC), clinical psychologist, leads child care discussion 



A pediatric nurse practitioner 
sees up to 15 patients during a 
two-hour clinic session. Guidance 
and counseling are provided by the 
Midway Island chaplain, a volun- 
teer counselor (also a military wife), 
and a Navy child psychologist who 
visits twice a month. Five more vol- 
unteers provide play therapy for 
children during clinic hours. 

Vital concerns. Services include 
free baby sitting, vaporizer and crib 
loans, well-baby checkups, acute 
minor illness care, immunizations, 
and transportation to hospital 
clinics. Health information and 
classes are also provided by the 
nurses. The classes cover a range of 
topics of vital concern to the fami- 
lies: management of child behavior, 
newborn care, breast feeding, con- 
traception, nutrition, alcoholism, 
and marriage problems. Also in- 
cluded, and attended enthusiastic- 
ally by the families, are discussions 
of money management, gun safety, 
and how to handle door-to-door 
salesmen. 

The Health Center has helped re- 
solve the isolation of the families 
and has begun to foster a commu- 
nity spirit. Even though the center 
has no fixed budget, it has thrived 
because of the supportive "help 
your own" spirit prevalent in the 
Marine Corps. Total cooperation by 
the Red Cross, the Naval Hospital, 




Cheryl Kosits, clinic director (right), 
helps with a diaper adjustment 

under the auspices of the Naval 
Hospital Quantico Pediatric Service, 
the Health Center's staff is made up 
chiefly of volunteers. Nine of these 
volunteers are registered nurses 
and wives of active-duty Marine 
Corps personnel. Staff members 
work as Red Cross volunteers but 
wear informal civilian attire rather 
than the Red Cross uniform. The 
Red Cross provides liability insur- 
ance for the volunteer nurses, all of 
whom are identified by a Red Cross 
name pin bearing their first name, 
followed by the letters R.N. 



wives' clubs, and chapel organiza- 
tions has ensured the Health Cen- 
ter's longevity. 

The Health Center augments 
civilian community resources, and 
staff members work closely with 
community social and law enforce- 
ment groups — especially to help 
combat child abuse. 

Although difficult to document, 
the many benefits accruing to the 
military commands include fewer 
military members from Midway 
Island being absent without leave or 
late for work, as well as lower acci- 
dent rates among Midway Island 
service members. That such bene- 
fits are real is attested to by the 
chaplains who work closely with this 
group, and by their military com- 
mands. 

Future plans. The work of the 
Health Center succeeds primarily 
because of the dedicated efforts of 
several nurses, including Jo Bahry, 
Kathy Nelson, Pat Christiansen, 
Cheryl Kosits, and Brenda Hicks. 
Also instrumental is cooperation of 
the American Red Cross, under the 
direction of COL E.J. Driscoll, 
USMC. Chaplains Herbert Bergsma 
and So! Rubino offered constant in- 
spiration, especially in the center's 
uncertain early days. LGEN J.C. 
Fegan, USMC, Commanding Gen- 
eral of the Marine Corps Develop- 
ment and Education Command, was 
wonderfully supportive, especially 
in renovating the Community Cen- 
ter. Pediatric nurse practitioner LT 
Donna A. Pence (NC) enthusiastic- 
ally provided health care, and CAPT 
R.F. Schindele (MSC) then com- 
manding officer of Naval Hospital 
Quantico, was a strong supporter of 
this project from its inception. 

Future plans include applying for 
a grant to provide free child care 
service any hour of the day to fami- 
lies in crisis. Funding may also be 
needed to hire a social worker, be- 
cause the problems of Midway 
Island families appear to be more 
sociological than physiological. 



Volume 69, April 1978 



Nephrology Progress at NRMC Oakland 



Back in 1952, when NRMC Oak- 
land made first use of its new "arti- 
ficial kidney," the bulky apparatus 
looked something like a cross be- 
tween an iron lung and a space-age 
washing machine. 

Today the "Oak Knoll" hospital's 
hemodialysis equipment is more 
compact, but its life-saving mission 
hasn't changed. 

"Dialysis is really a tremendous 
service available here at Oak 
Knoll," says CAPT John D. Wallin 
(MC), head of Nephrology and 
director of the Clinical Investigation 
Center at the 413-bed hospital. "It 
saves the patients a fair amount of 
money, because the cost of this 
treatment is quite high in civilian 
hospitals. Right now, we're taking 
care of eight patients who would die 
if they weren't dialyzed three times 
each week." 

Over the last five years, since Dr. 
Wallin has been at Oak Knoll, 



around 55 kidney patients — active- 
duty Navy, dependents, and retired 
military personnel — have received 
dialysis treatment. Of these, 15 
have received kidney transplants. 

Wallin and his staff of hospital 
physicians, resident doctors, and 
corpsmen are active in a number of 
research projects involving kidney 
disease and resultant hypertension. 
Wallin himself has spent much of 
the last five years working on re- 
search into water metabolism as it 
relates to kidney disease. 

"The kidneys filter about 60 
gallons of blood each," he says, 
"but they do a second job on the 
blood plasma — recovering the 
water, salt, and other materials the 
body needs to survive. There are 
hormones that affect the way water 
is recovered, and there are drugs 
used in everyday clinical practice 
that interfere with the effects of 
these hormones on the kidneys. My 



Dr. John Wallin monitors a patient during hemodialysis. The machine is one of five 
currently in use for kidney patients at Oak Knoll 




principal area of research involves 
looking at the mechanisms with 
which some of these drugs interfere 
with the hormones." 

One of the more innovative pro- 
grams at Oak Knoll is the Hyper- 
tension Clinic, established three 
years ago as a research project to 
see whether a system could be de- 
vised to fully care for a chronic dis- 
ease without requiring extensive 
physician time. 

"What we set up was a clinic that 
uses a select group of paramedical 
people whom we trained in the 
management of hypertension," 
says Dr. Wallin. "To support them, 
we use a computer bank that stores 
all the patient data regarding side 
effects either to the disease or medi- 
cations. It then determines the 
blood pressure and gives recom- 
mendations as to medication. This 
allows the nurse practitioner and 
regular medical corps people to 
regulate medication to control the 
patient's blood pressure." 

Thus far, the clinic has treated 
more than 4,000 patients. 

NRMC Oakland is "probably the 
only place in the country where 
something like this has developed," 
Wallin notes, "and we can handle 
16,000 annual visits with less than 
one physician-year of time ex- 
pended." 

A 1962 graduate of Yale Univer- 
sity School of Medicine, CAPT 
Wallin says he has found the Navy 
to be "full of dedicated young 
people who are well trained, ex- 
tremely well qualified, and who 
practice superb medicine." 

"I think we're delivering health 
care in the upper ten percent of 
medicine practiced in the country," 
he adds, "and it's been a very 
pleasant experience for me." 



— Story by J03 John Brindley. Photo by 
PH2 Bob Weissleder. 



U.S. Navy Medicine 



Notes & Announcements 



IN MEMORIAM 

RADM William W. Hall, MC, USN (Ret.), whose 
work in tetanus immunizations saved countless lives, 
died 6 Jan 1978. 

Born in Minto, N. Dakota, on 18 Oct 1892, RADM 
Hall attended the University of Minnesota and Medical 
School, receiving his Bachelor of Science degree in 
1916, and Bachelor of Medicine and Doctor of Medicine 
in 1918. He was in the inactive Naval Reserve from 
March 1919 to June 1920. Returning in June 1920 to 
active duty in the Navy Medical Corps as a lieutenant, 
junior grade, he reported to the Naval Hospital, San 
Diego, Calif., and subsequently served in many naval 
ships and hospitals, advancing to the rank of Captain in 
1942. He served as Chief of the Research Division, BU- 
MED, from May to September 1946. He was then as- 
signed as senior medical officer of the Puget Sound 
Navy Shipyard, Bremerton, Washington, where he re- 
tired 1 Oct 1949. He was advanced to the rank of Rear 
Admiral on the basis of combat awards. 

RADM Hall received a Letter of Commendation with 
Ribbon from the Secretary of Navy, which reads in part: 
"For outstanding performance of duty in connection 
with the development of tetanus toxoid immunization in 
the Navy. Beginning his studies with volunteers from 
the crew of the USS Relief in 1934, RADM Hall devel- 
oped this important factor of preventive medicine to a 
high degree of effectiveness, enabling the entire stu- 
dent body of the U.S. Naval Academy to receive this 
immunization in 1938. Prior to and during the period of 
National Emergency, he recommended the immuniza- 
tion of the Marine Corps and Navy personnel with alum 
precipitated tetanus toxoid. This method was used by 
the Navy with the result that no combat casualty in the 
Navy and Marine Corps developed tetanus during 
World War II." 

RADM Hall was a Fellow of the American College of 
Physicians, Diplomate of the American Board of Pathol- 
ogy in Pathologic Anatomy and Clinical Pathology, 
Diplomate of the American Board of Internal Medicine, 
Fellow of the College of American Pathologists, and 
Member of the California Society of Pathologists. He 
held the Legion of Merit with combat "V", Navy Com- 
mendation Ribbon, World War I Victory Medal, Second 
Nicaraguan Campaign Medal, American Defense Ser- 
vice Medal, American Campaign Medal, Asiatic-Pacific 
Campaign Medal with two bronze stars, and the World 
War II Victory Medal. 



CAPT Milton R. WirthUn, MC, USN (Ret.), a former 
Navy physician who served 30 years with the Navy 
Medical Corps, died 13 Feb 1978 in Little Rock, Ark. 




CAPTM.R.Wiithlin 
1905-1978 



Born in Minturn, Ark., on 9 
May 1905, CAPT Wirthlin re- 
ceived his Bachelor of Science 
degree in 1927, and his M.D. 
degree from the University of 
Arkansas School of Medicine in 

1929. He was commissioned a 
LTJG in the Medical Corps of the 
U.S. Navy on 4 June 1929, and 
interned as ward medical officer 
at Naval Hospital, Brooklyn, 
N.Y., and in the out-patient de- 
partment of the Third Naval Dis- 
trict Headquarters. In December 

1930, he was assigned to the na- 
val base at Guantanamo Bay, 
Cuba, and after six months was reassigned as medical 
officer on the USS Brazos. 

CAPT Wirthlin subsequently served in many duty 
assignments including two years with the Physical 
Qualifications and Medical Records Section at BUMED. 
He then joined the USS Massachusetts. While on board 
that battleship, he participated in Atlantic patrols off 
Norway, the landings at Casablanca, Pacific operations 
in the Gilberts, the occupation of Kwajelein and Majuro 
atolls, the Truk and Marianas attacks, and raids on 
Palau, Yap, Ulithi, and Woleai. 

CAPT Wirthlin returned to BUMED in 1944, as as- 
sistant to the personnel officer. In 1945, he reported as 
executive officer at Naval Hospital, Annapolis, Md. 
After a course in general surgery at the University of 
Pennsylvania, he served on the surgical staff at Naval 
Hospital, Oakland, Calif., and as Chief of Surgery, 
Naval Hospital, Newport, R.I. This was followed by a 
tour as executive officer at Naval Hospital, Quantico, 
Va. 

He was officer in command of the hospital aboard the 
USS Consolation when the helicopter deck innovation 
was initiated for Korean combat medical evacuation, 
and also during the resettlement of Vietnamese civil- 
ians. He then commanded the naval hospitals at Quan- 
tico, Va., and Newport, R.I. His last tour of active duty 
was as senior medical officer of the Naval Station, San 
Diego, Calif., and as assistant district medical officer, 
Eleventh Naval District. 

After retiring from the Navy in 1959, Dr. Wirthlin 
became County Medical Director in Pine Bluff, Jeffer- 
son County, Ark., and was President of the Arkansas 
Public Health Association from 1962 to 1963. In 1969, 
he was medical officer for the Contra Costa County, 
California, Health Department. He returned to Little 
Rock, Ark., in 1973, where he lived until his death. 

CAPT Wirthlin was a Fellow of the American College 



Volume 69, April 1978 



5 



of Surgeons and held the Navy Commendation Medal, 
China Service Medal, American Defense Service 
Medal, American Campaign Medal, Asiatic-Pacific 
Campaign Medal with three stars, World War II Victory 
Medal, National Defense Service Medal, Korean Ser- 
vice Medal, United Nations Service Medal, and the 
Vietnamese Presidential Unit Citation. 



SURGICAL PATHOLOGY COURSE 
SET FOR JUNE 

The Armed Forces Institute of Pathology (AFIP), in 
collaboration with the American Registry of Pathology, 
will hold a Surgical Pathology for General Surgeons 
course 12-16 June 1978. This is the first course to be 
given at the AFIP designed specifically for the general 
surgeon. 

Course content will cover lesions of organs and 
systems handled by general surgeons, and lesions 
which a general surgeon may encounter in emergencies 
or in geographic areas where surgical specialties are 
not readily available. 

There will be no registration fee for military and 
other federal attendees. The registration fee for non- 
federal participants will be $250. All participants in this 
course will receive AMA continuing education credits. 

Military and federal surgeons may obtain further in- 
formation by writing to: The Director, Armed Forces 
Institute of Pathology, ATTN: AFIP-EDE, Washington, 
D.C. 20306. Nonfederal surgeons may write to: The 
American Registry of Pathology, ATTN: Dr. C.H. Bin- 
ford, Armed Forces Institute of Pathology, Washing- 
ton, D.C. 20306. 



DENTAL CORRESPONDENCE COURSE REVISED 

The Dental Corps has revised its correspondence 
course, "Operative Dentistry" (NAVEDTRA 10759-B), 
designed for dental officers in general practice. The 
course is based on the text Principles and Practice of 
Operative Dentistry, by G.T. Charbeneau, et al. (Lea 
and Febiger, 1975). 

In six assignments, the course covers examination, 
diagnosis, and treatment planning; occlusion, caries, 
periodontia! aspects of operative dentistry, and 
preventive measures; instrumentation, the biologic 
basis of restoration, and general operative treatment 
procedures; amalgam restorations; cohesive and cast 
gold restorations; and conservative complex esthetic 
restoration of devital teeth. It is evaluated at 12 points 
for Reserve retirement credit by the Armed Forces, and 
for continuing education credit by the Academy of Gen- 
eral Dentistry and 10 states. Dental officers who com- 
pleted the former course in "Operative Dentistry" 
(NAVPERS 10759-A) may receive full credit for this 
course. 

The course in operative dentistry is one of a series of 
correspondence courses sponsored by the Dental Divi- 



sion, BUMED. The courses are open to all dental offi- 
cers on active duty with the U.S. Armed Forces or other 
Federal agencies, to Reserve officers on inactive duty, 
and to dental officers of armed forces of friendly na- 
tions. 

Descriptions of the courses, eligibility requirements, 
and application procedures are given in U.S. Navy 
Dental Corps Correspondence Course Program, NAV- 
MED P-5081, which is available from the Commanding 
Officer (Code 413B), National Naval Dental Center, 
Bethesda, Md. 20014. 

MEDICAL FILM AND VIDEOTAPE 
CATALOG UPDATED 

The HSETC Medical Film and Videotape Catalog has 
been updated. Return all catalogs dated before 1978 for 
recycling to: Audiovisual Resources Division, Code 26, 
Naval Health Sciences Education and Training Com- 
mand, National Naval Medical Center, Bethesda, Md. 
20014. 

The updated catalog will be remailed to you within 
one week after receipt. Please enclose a self-addressed 
mailer with your old catalog. 

NEW ORGANIZATION FOR NAVY 
EMERGENCY MEDICINE PHYSICIANS 

Last year MAJ Gerald Whelan, an Air Force physi- 
cian at Malcolm Grow USAF Medical Center, gathered 
five members of the American College of Emergency 
Physicians (ACEP) to sign a petition that resulted in the 
official recognition by ACEP of a government services 
chapter. 

The first organizational meeting was held last No- 
vember during the ACEP Scientific Assembly in San 
Francisco, Calif. Chapter by-laws were tentatively ac- 
cepted, and an ad hoc committee was formed with MAJ 
Whelan as chairman. 

The committee's goal is to circulate information 
about the new chapter and to encourage membership. 
Formal election of officers, appointment of committees, 
and other matters will be handled at the 1978 ACEP 
Scientific Assembly in Texas. 

Government services chapter membership is open to 
any federal physician actively involved in emergency 
medicine. Physicians who are already active in ACEP 
and are interested in joining the government services 
chapter may telephone (517) 321-7911. Applications to 
join ACEP may be obtained by writing to: American 
College of Emergency Physicians, 3900 Capital City 
Boulevard, Lansing, Mich. 48900. Application fee is 
$20. 

Navy physicians who decide to join the government 
services chapter should notify CDR Steven J. Hazen, 
MC, USN, Chief, Clinical Medicine Branch, Depart- 
ment of Family Practice, NRMC Jacksonville, Fla. 
32214. Telephone (904) 772-5321 or Autovon 942-5321. 
CDR Hazen will keep a list of Navy ACEP members. 



U.S. Navy Medicine 



On Duty 



Dental Technician: 



A Life with Goals-and Rewards 



It's no secret that a child's first 
experience in a dental chair can 
make him a reluctant dental patient 
in later life. 

In his work at Naval Regional 
Dental Center, San Diego, DT2 
Robert M. Fraser sees a number of 
apprehensive patients who would 
have gone out of their way to avoid 
dental care if regular dental check- 
ups were not mandatory in the 
Navy. 

A clinical dental technician at the 
Navy's newest and most modern 
dental facility, Fraser has made it 
his personal goal to make each pa- 
tient's visit as pleasant as possible. 
"If you can provide good treatment 
and show that you're conscien- 
tiously interested in the patient as a 
person, not just a number, that pa- 
tient is going to come back." 

Fraser, the leading petty officer 
of the Oral Diagnosis Department, 
and other staff members were in- 
strumental in providing a smooth 
transition after NAVREGDENCEN 
moved from its old quarters last 
June into a new, consolidated facil- 
ity. 

"I've seen more people come 
back on their own for treatment, 
since we've moved into this build- 
ing, than I have in my last 11 years 
in Navy dentistry," says Fraser. "It 
all depends on the care you give, 
and most of the people are happy 
about the service here." 

The Naval Regional Dental Cen- 
ter Headquarters has seven clinical 
departments which include opera- 
tive dentistry, periodontics, oral 
diagnosis, endodontics, preventive 
dentistry, oral surgery, and pros- 
thetics. Currently, the clinic is 
staffed by 32 dentists, 15 laboratory 
technicians, and 34 clinical techni- 







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re 







cians. The regional dental center 
and its branch dental clinics were 
responsible for treating the 432,000 
active-duty and retired patients 
seen last year in the San Diego area. 
The center supplies and services 
several branch clinics from North 
Island to as far away as El Centro, 
California, 120 miles to the east. Pa- 
tients from ships that do not have 
dental facilities are treated on a 
priority basis. 

For Petty Officer Robert Fraser, 
as for many more of the Navy's 
dental technicians at other com- 
mands, the technician's job has an 
intangible but highly satisfying 
benefit. 

"When someone calls you back 
for an appointment and specifically 
asks for your assistance, "Fraser 
says, "you have your reward." 

— Story contributed by J03 John Brindley. 




DT2 Fraser pulls a dental chart (above) and assists Dr. Manuel Carrillo (left) with 
an oral examination. Photos by Bob Weissleder 



Volume 69, April 1978 



Features 



Medical Records - Good and Bad 



Dorothy C. Raslnski, M.D., J.D. 



In today's medicolegal climate, practitioners of medi- 
cine have been admonished ad nauseam about the need 
to keep accurate, clear medical records. If we physi- 
cians were to follow all this advice, we would become 
like squids, propelling ourselves backwards by the ex- 
pulsion of great quantities of ink. 

Memorizing a litany of platitudes or mechanical 
"Dos and Don'ts" on medical recordation is not neces- 
sary. Rather, the physician should be encouraged to 
develop a conceptual and attitudinal approach to medi- 
cal records that will make him or her more effective in 
recordation, and will therefore conserve both time and 
effort. 

It is important at the outset to list four empirical as- 
sumptions that are accepted as "Gospel" by most 
medicolegal experts: 

• A bad result and a bad record equal liability, regard- 
less of the quality of care rendered. 

• In a malpractice trial, medical records are the most 
important evidence, regardless of the facts. 

• Although physicians may be the "medical experts," 
attorneys have become the "medical records experts." 

• As experienced defense attorneys frequently counsel 
their defendant- physician clients: "If you have done 
everything you should with your medical records, I will 
be able to do everything I can for you in defense of a 
medical malpractice suit." 

Why such great emphasis on medical records? 

The answer lies in the relationship of medical records 
to the "standard of care" — and, in particular, to the 
manner in which the law uses medical records to deter- 
mine whether or not a physician has deviated from the 
standard of care. In actual practice, it is difficult to con- 
sider these two concepts independently. 

In malpractice cases, the court is primarily concerned 
with assessing a physician's professional conduct to 
determine whether such conduct deviated from the 
standard of care required by the law and by medicine. 
Professional records are a legal index or guide to one's 
professional conduct. They relate directly to a physi- 
cian's capability and, in a very special way, to his credi- 
bility as a matter of law. 

Dr. Rasinski is assistant chief, Division of Legal Medicine, Armed 
Forces Institute of Pathology, Washington, D.C. 20306. 



There is a feeling common among physicians that 
judges are attempting to tell them how to practice 
medicine. In support of this contention, the cases Hell- 
ing v. Carey (83 Wash. 2d 514, 519 P. 2d 981, 1974) and 
Canterbury v. Spence (464 F. 2d 772, 1972) are often 
cited. In both these cases, in finding negligence, the 
court appeared to ignore or overrule a thoroughly ac- 
cepted medical standard of care. In the first case, the 
standard of care related to screening procedures for 
glaucoma; in the other, to a test of the adequacy of "in- 
formed consent" prior to a surgical procedure. 

The courts' opinions in these cases were not really 
directed to physicians but were intended to put 
practicing attorneys on notice. In these opinions and 
others like them, courts have attempted to identify 
what they feel are the most significant features, charac- 
teristics, and aspects of professional conduct. The 
courts are not specifically concerned with who should 
be given a glaucoma test, for example — they admit they 
lack the expertise to make such a determination. 
Rather, the instructions given in a legal opinion are for 
application, not to the issue of how to practice medi- 
cine, but to how a physician should conduct himself in a 
professional manner. 

Many times, in effect, courts' opinions mirror 
society's expectations. The hoped-for result is that at- 
torneys will become more adept at assessing profes- 
sional conduct and developing a workable, meaningful 
concept of a "standard of care" as a reasonable guide 
to acceptable conduct. 

Because legal opinions represent a retrospective 
analysis, courts and attorneys must rely heavily upon 
medical records. Therefore, judges are instructing at- 
torneys as to what to look for in the medical record, 
especially as it may be a barometer of the standard of 
care delivered by the physician. 

The "standard of care" is a difficult and subtle con- 
cept because it tends to be predominantly subjective in 
nature. All physicians ask for a formula or definition, an 
objective guide as to what the standard of care is. "If I 
knew what it was, I would follow it," they tell us. 

Unfortunately, there are no cookbook responses to 
such inquiries. But a condensed answer is that "stan- 
dard of care" is the requirement that a physician "use 
his best judgment under the circumstances." This is 



U.S. Navy Medicine 



not a simple abstraction, but rather a legal term of art, 
developed over the course of years within the common 
law. It provides us with those guidelines we must apply 
to discern our legal duties as professionals. 

The problem is that this requirement is deceptively 
simple. As a result, some physicians have attempted to 
use it as a shield when a bad result occurs during the 
course of their professional performance. They say, "I 
used my best judgment," as if there were something 
magical in the phrase. But this naked assertion is in- 
sufficient to provide an adequate explanation of 
behavior, and it may be inherently self-serving in 
nature, 

THE 'BEST JUDGMENT' REQUIREMENT 

To understand how the requirement to "use one's 
best judgment" relates to medical records, it is impor- 
tant to examine the two elements that fall under the 
requirement: (1) A physician must possess knowledge, 
and (2) he must exercise or apply that knowledge in a 
skillful and careful manner. These are the essential 
prerequisites that allow a physician to rely upon his 
professional judgment. And they relate in a very 
specific way to medical records. 

It is incumbent upon the practicing physician to dem- 
onstrate these elements in his medical records, if at 
some later point he hopes to be able to use them to 
justify his professional behavior and conduct. Let us 
examine these crucial elements more closely. 

Possession of knowledge. This element requires a 
demonstration that a physician is qualified to act on his 
judgment. "Knowledge," to the law, means education, 
training, and experience. Education refers to medical 
education, which is grounded in the biosciences, i.e., in 
the pathophysiologic mechanisms of health and dis- 
ease. Courts are quite impressed with science. They 
recognize that it is somewhat beyond their expertise. 
They give immense credibility to behavior or conduct 
that is put in a scientific framework. Training is the 
second aspect of knowledge, and it refers to clinical 
experience and the "art" of medicine. It is reflected in 
certain procedures such as history-taking and physical 
examination. The third aspect of knowledge is experi- 
ence, and this refers to the utilization and application of 
the physician's medical education and training, 

Medical records should be a pertinent demonstration 
of a physician's application of education, training, and 
experience to a particular case or situation — not merely 
a pedantic parade of medical jargon. It is important that 
the records reflect some evidence of familiarity with the 
so-called Medical Model, i.e., medical methodology. 
While there is a legal presumption that a graduate of an 
accredited medical school, who possesses a state li- 
cense, possesses medical knowledge, this presumption 
is not conclusive. It can be rebutted if the physician has 
made such careless mistakes in his workup as recording 
frivolous comments, including the vernacular, or mak- 



ing moral judgments. For example, consider the physi- 
cian who writes in his chart, "Joe's problem is his wife: 
she's a bitch on wheels," or "If this man spent less 
time running around with floozies and hookers, he 
would not have an ulcer." Both these statements may 
be accurate, but they are not couched in terminology 
that reflects medical training. 

Again, the physician is evaluated qua physician, that 
is, in his role as a physician. One should not forsake 
evidence of his or her professional discipline or method 
by becoming too informal or nonmedical in recorda- 
tion. 

Application of knowledge. The second element of the 
"best judgment" requirement is that the physician 
must exercise or apply his knowledge in a skillful and 
careful manner. There is no presumption that a physi- 
cian always automatically does so. Therefore, courts 
carefully scrutinize this aspect of a physician's profes- 
sional conduct. 

"Skill," in the eyes of the law, represents clinical 
competence, i.e., the effective and judicious utilization 
and application of medical knowledge. At the very 
least, this would seem to require that medical records 
(1) establish the probable cause of the patient's prob- 
lem, (2) justify the diagnosis, and (3) delineate the 
treatment and management. This, in effect, means 
gathering salient facts and formulating them for use in 
the differential diagnostic process. The bland assertion 
that "Mrs. Jones has a URI" is of no medical value. A 
receptionist or an untrained layman could reach the 
same conclusion. It requires no special training and 
certainly evinces no professional skill. 

A very crucial aspect of medical recordation is the 
formulation of a differential diagnosis. The medical 
records should tell a clinical story of the patient's prob- 
lem, not in the form of a simple narrative or a technical 
task easily performed by nonphysicians. 

The formulation is a process of rational decision- 
making, i.e., selecting those pathologically germane 
facts and synthesizing them into a differential diagno- 
sis. This is the crux of the medical professional's 
mental processes. Medical records give clues about 
one's professional thinking. They also can be used to 
minimize the risk that diagnostic or therapeutic deci- 
sions will be impugned or perverted at trial by the 
plaintiff's counsel. 

It should also be noted that the professional conduct 
of the physician must be consistent with the formula- 
tion as reflected in his medical records. If not, the medi- 
cal records should somehow reconcile, by appropriate 
comment, the disparity between thought and action. 
Failure to provide such reconciliation has been respon- 
sible for raising a substantial inference of incompetence 
on the part of a defendant physician. 

An additional qualification should be made about the 
"best judgment" requirement. That requirement 
relates to one's best judgment "under the circum- 
stances." Therefore, it is important that we record 



Volume 69, April 1978 



9 



special circumstances under which the patient is evalu- 
ated. For example, the circumstances of an emergent or 
urgent situation, or the fact that one was dealing with a 
hostile, uncooperative, intoxicated, or incompetent pa- 
tient, should be recorded. 

THE 'REQUIREMENT' AND MEDICAL RECORDS 

Two court cases can be cited as examples to illustrate 
the legal meaning of the "best judgment" requirement 
and its relationship to medical records. 

In one case, a newborn was found to have a serious 
Rh incompatibility. Exchange transfusion was begun on 
the date of birth. The physician decided to halt the ex- 
change prematurely, when the infant became cyanotic, 
and it was not resumed for four days. In the interim, the 
infant developed deep jaundice and kernicterus. 

The physician was accused of negligence in delaying 
the exchange transfusion. He testified at trial that he 
had been aware that the bilirubin level was vitally im- 
portant in the care of this patient, and that he had 
ordered serum bilirubin levels every eight hours, as 
well as constant monitoring. 

The medical records, however, did not corroborate 
the physician's testimony. There was no indication in 
the records that the infant had remained cyanotic, or 
that any tests had actually been performed. No results 
of such tests were recorded, and there was no evidence 
in the medical record of any monitoring. That physi- 
cian's records, therefore, became a source of suspicion, 
especially with reference to his credibility. They also 
raised doubts about his capability and competence. 

The court held that sufficient evidence could be 
adduced to raise the inference that the physician had 
not undertaken adequate analysis upon which to exer- 
cise his professional judgment. The court concluded 
that the decision to delay the transfusion was not based 
on careful analysis; therefore, the physician was found 
to have been negligent. 

While in that instance medical records impaled the 
physician, they can be of redeeming value in cases 
where bad results ensue or poor judgment occurs. This 
can be seen from our second example. 

A 5-year-old girl presented with right-lower-quadrant 
abdominal pains and a history of vomiting and fever. 
She was examined by a physician who ordered a CBC 
and flat and upright X-rays of the abdomen. The films 
disclosed a localized reflex ileus. 

The physician's diagnosis was tonsillitis, for which 
he prescribed penicillin. The patient was then sent 
home. A few days later, the child was admitted to the 
hospital with a ruptured appendix and peritonitis. 

The physician's medical records indicated that he 
had examined the abdomen but had found insufficient 
signs upon which to base a diagnosis of appendicitis or 
of an acute abdomen. The tonsils had appeared red. 
The physician said he had felt that the white blood 
count was more compatible with tonsillitis than with 



other disorders, under the circumstances. 

The patient was deemed entitled to a thorough exam- 
ination, conducted with customary diligence and 
methods of diagnosis. (Presumably, these include 
history, physical examination, and laboratory tests.) 
The diagnosis of tonsillitis had been based on physical 
examination and laboratory findings; it was supported 
by evidence in the medical records and not based solely 
on intuition. Therefore, even though the findings were 
consistent with other disorders, the physician was not 
considered to have been negligent. Thus, it can be seen 
that in many cases the actual diagnosis may be less im- 
portant than the means or method by which it was 
reached. 

"Professional judgment" can be a shield from liabil- 
ity that may follow an error in diagnosis, but only when 
careful formulation of the problem turns out to have led 
to the incorrect diagnosis. And medical records are the 
best evidence of careful formulation. 

Laymen cannot conceive of or appreciate the complex 
nature of the diagnostic process. The law formally rec- 
ognizes this complexity; and its recognition is reflected 
in certain procedural requirements of malpractice 
cases, in particular the requirement that the standard 
of care be generally set by an expert medical witness, 
i.e., a qualified physician. This is tacit recognition of 
the uniqueness and uncertainty of clinical medicine. 
However, if we become careless in adequately and ac- 
curately recording our method and discipline, we may 
convince courts that the diagnostic process is not as 
complex as has heretofore been believed. This is espe- 
cially true if we do not use proper terms and methods 
that reflect our medical education and training. If this 
happens, we may well lose some of the procedural priv- 
ileges we now possess in the trial of malpractice cases. 

Medical records should reflect the complexity of a 
difficult clinical problem. If they do, they will demon- 
strate to a court that the proper professional attention 
has been given to the medical problem. The law does 
not ask much more. If one is aware of what the law 
requires in medical recordation, he will be protected, 
and good medical care will be promoted. 

IMPORTANCE OF GOOD RECORDS 

It has been said over and over that one of the most 
important things a physician can do to protect himself 
and reduce his malpractice exposure is to keep good 
medical records. 

It is estimated that 20% to 25% of the malpractice 
claims referred to the Legal Medicine Division of the 
Armed Forces Institute of Pathology are rendered in- 
defensible or are seriously compromised because of 
inadequate medical records. This has cost the govern- 
ment hundreds of thousands of dollars each year for the 
last several years, to say nothing of the loss in the 
private sector. The problem has manifested itself in 
increased risk of suit; increased percentage of losses; 



LO 



U.S. Navy Medicine 



increased amounts in settlements paid, verdicts ren- 
dered, judgments awarded; and increased malpractice 
insurance premiums paid by the profession at large. 

Why are medical records so critical to such a large 
percentage of claims? One reason is that most physi- 
cians see too many patients to have any independent 
memory of their contact with any single patient. 
Furthermore, the trial of a medical malpractice suit 
may occur anywhere from two to ten years after the 
alleged negligent act. The medical record therefore be- 
comes invaluable to the defense, because memory 
alone is less than worthless, and the record may serve 
to refresh the doctor's recollection of events long past. 

Judges and jurors are likely to be suspicious of any 
physician who lacks a record of some vital fact essential 
to his defense. When, as often happens, a lawsuit be- 
comes a question of "Whom do you believe?" — the pa- 
tient, testifying "He didn't," or the doctor, testifying 
"I did" — the availability of contemporaneous records 
corroborating the doctor's recollection will frequently 
tip the scale of credibility decisively in his favor. 

An attorney will have several basic concerns in 
reviewing a medical record. 

First and foremost, he will want to be sure that it is 
legible, though he often may not understand the physi- 
cian's comments and observations. An illegible scrawl 
may be the way we were forced to learn to write to keep 
up with lecture material in medical school, and this 
habit may unfortunately follow through to the writing of 
progress notes, orders, or prescriptions. But the plain- 
tiff's counsel or the defense attorney or judge who 
reviews such a record will not be particularly impressed 
by that excuse. The attorney may not be able to write 
any better than you can, but his actions are not on trial. 

For the sake of the defendant physician and his 
attorney, then, records should be kept in good condi- 
tion. It is very distressing to the defense counsel to 
have to introduce evidence based on taped-together, 
dog-eared, coffee-stained, and ink-blurred documents 
that may be impossible for even the defendant to 
read — or that contain illegible scratchings and abbre- 
viations known only to the recorder and God. These 
records may be admissible and may constitute the 
entire "defense," but they certainly will not help the 
defendant's professional image. 

Sloppy records have also resulted in overdose deaths. 
The problem of decimal point errors should be con- 
sidered: e.g., the matter of 3 N against .3 N saline, or 
25 mg Compazine against 2.5 mg for a child. 

Lest one be misled, primary-care physicians are not 
the only ones who make these mistakes. Others, includ- 
ing pathologists, can be involved. 

One example occurred during a criminal trial based 
on the death of a woman during an illegal abortion at- 
tempt. Analysis of brain tissue showed the presence of 
chloral hydrate. Considering the pathologist's analysis 
of the percentage of chloral hydrate in the brain and the 
victim's body weight, the defense counsel calculated 



that the woman had ingested 20 chloral hydrate cap- 
sules, which could be considered a suicidal dose. The 
court had no choice but to find reasonable doubt as to 
cause of death and acquit the accused on the man- 
slaughter charge, although it found him guilty of at- 
tempted abortion. 

What had happened? The pathologist had misplaced 
his decimal point. If one moved the decimal place one 
point to the left (where it belonged) in the pathologist's 
report, calculations would show that before undergoing 
the attempted abortion, the woman had taken only two 
chloral hydrate capsules, a reasonable dose. 

There was no way out of this decimal point trap. Not 
only were there criminal implications, but also the error 
might have been compounded if claim had been made 
that death had occurred within the two-year suicide 
presumption clause of the decedent's life insurance 
policy, and her heirs had been able to recover only pre- 
miums paid plus interest, instead of the face value of 
the policy. 

Radiologists, too, can be involved. In another case, a 
radiologist had been criticized by his chief for rubber- 
stamping "normal chest" on X-ray reports. Perhaps 
the radiologist thought to himself, "Okay, the next 
routine pre-op chest film I see will really get a thorough 
commentary." And the next "routine pre-op" chest 
film to cross his desk belonged to the husband of one of 
the hospital's record-room employees. The patient had 
been admitted for elective cholecystectomy. The radiol- 
ogist dictated this very extensive report: 

Examination of the chest reveals normal thoracic cage. The dia- 
phragms are symmetrical. The heart is normal in size. The aorta is 
slightly tortuous. The cardiac configuration suggests a remarkably fit 
individual who certainly has a heart many years younger than his 
stated age of 55 years. The anterior musculature of the chest wall is 
also quite prominent, again suggesting a very vigorous and healthy 
person who has lived a clean life and must be the product of an 
extremely happy home life and excellent care. CONGRATULATIONS 
TO HIS WIFE. 

Normally, of course, a routine preoperative chest Film 
is taken to demonstrate any pulmonary pathologic con- 
dition that might contraindicate the use of general 
anesthesia. But this report, though extensive, makes no 
mention of the lung fields. 

Further, by the time the X-ray report had found its 
way into the medical record, the patient was in the 
morgue, the victim of a clostridial wound infection and 
peritonitis. The widow's associates in the record room 
were quick to point this out to her, and she filed suit. If 
the surgeons who had treated her husband had as 
cavalier an attitude as the radiologist, she reasoned, 
the "malpractice" or lack of concern for her husband 
was obvious. 

Fortunately, there was no malpractice in the surgical 
care and postoperative treatment of this patient. But if 
there had been some question and the case had had to 
be tried on its merits, one can imagine the consterna- 
tion in trying to explain the radiologist's comments, 



Volume 69, April 1978 



11 



even though he had had no direct involvement in, or 
relationship to, the patient's demise. The moral here, 
as we mentioned earlier, is "Keep your remarks in the 
chart professional." 

Another case in which frivolous comments were 
made involved a patient who entered a hospital for 
regulation of L-dopa treatment for Parkinson's disease 
following bilateral chemopallidectomy. A neurologist 
had been called in consultation, and in his physical 
examination remarks, under "neurological status," he 
wrote: "No pathological reflexes, except pink slip- 
pers." 

Two weeks later, the patient was brought by his wife 
to the emergency room of the same hospital for treat- 
ment of chest pains, shock, difficulty in breathing, and 
cyanosis. An electrocardiogram revealed evidence of 
acute myocardial infarction, but the tracing was read by 
a surgeon resident, who had no experience with cardio- 
grams, as "perfectly normal." The patient was sent 
home, where he died that night in bed. 

Obviously, the defense would have to answer an 
allegation of malpractice in the handling of the cardiac 
problem. But the extraneous, inappropriate comment 
regarding the patient's neurological status — made two 
weeks before the patient's death, under entirely differ- 
ent circumstances — only added to the "damages" in 
this case, and to the widow's mental anguish and dis- 
tress. 

Such remarks have no place in a medical record. Nor 
should the record be used — in the hospital, the outpa- 
tient clinic, the office, or anywhere else — as a battle- 
ground for a running feud. 

For example, one internist had always referred his 
patients who required surgery to a particular surgeon 
noted for his technical skill but not for his knowledge of 
postoperative intravenous fluid management. The sur- 
geon operated on a patient referred to him by the 
internist and then went ahead to write his own intra- 
venous fluid orders. The internist came by later the 
same day and, dissatisfied with the surgeon's instruc- 
tions, wrote across the progress notes, "This horse's 
may know a lot about surgery, but he knows absolutely 
nothing about fluids. Fluid orders changed — see order 
sheet." 

The surgeon made rounds early the next morning 
and wrote in the patient's progress notes, "If I am such 
a horse's — , why do you keep calling me back to do 
your surgery?" 

Unfortunately, the patient died of cardiac complica- 
tions. 

Absolutely no negligence or malpractice was 
involved in this case. But can anyone imagine the 
defense of this kind of record, if suit were ever 
brought? Obviously such a case would have to be 
settled out of court — the plaintiff's attorney sitting back 
comfortably relaxed while the defendant surgeon and 
the defendant internist argued about who was really 
responsible. 



Another example of an unfortunate, frivolous 
comment in a record involved a patient who suffered a 
cardiac arrest during delivery and remained in a coma 
for months. The medical record contained a laboratory 
slip that had been sent, together with spinal fluid, to 
Bacteriology for culture. Under the heading "diagno- 
sis," someone had written "postpartum blues." What 
a field day some plaintiff's attorney could have with 
that one! 

ALTERATIONS IN THE RECORD 

Perhaps the most prevalent type of malpractice 
bungler is the doctor who tries to make himself look 
better in hospital or office records after a claim notice 
has landed on his desk. 

It is bad enough to dictate records that do not ade- 
quately summarize diagnosis or treatment. But giving 
in to the temptation to alter the records when one is 
sued, or when there is a bad result, no matter how justi- 
fied one feels, can be even more disastrous. If the 
alteration is subsequently proved in court, juries uni- 
versally incline toward a commonsense question: If the 
doctor has nothing to cover up, why does he need to 
meddle with the records? 

Consider the case of a 4-year-old child with a three- 
month history of rectal bleeding. Clinical examination 
and workup revealed the presence of three sigmoid 
polyps, and laparotomy was performed to remove 
them. The patient did well immediately after the opera- 
tion, but on the second day she became lethargic, de- 
veloped a temperature of 102° F, and made some inap- 
propriate comments. At this point, serum electrolyte 
determinations revealed the sodium content to be 
greater than 170 mEq/liter and the chloride to be 122 
mEq/liter. 

The case was reconstructed as follows. The physician 
who had written the orders for intravenous fluids had 
wanted one-third normal saline given, and had written 
his order as "1/3 N saline" — or at least this is what he 
later insisted. In taking the order off the physicians' 
order sheet, the nurse had seen the "3" but not the 
other items, and had continued to hang up bottles of 3 
normal (3 N) saline. 

When the error was discovered, 48 hours later, the 
physician rewrote his order, now convincingly express- 
ing it as a fraction. The nurse denied that it had been 
written that way originally, insisting that she had seen 
no fraction. But the correction was obvious from the 
different size of the symbols, the different pen, and the 
heavier strokes used. 

When the malpractice claim was filed, the nurse's 
notes were as originally written. If the physician had 
bothered to read them daily, he might have caught the 
error much sooner, and the tragic end could have been 
avoided. The child died of renal shutdown. The parents 
recovered $20,000 in an out-of-court settlement. There 
is no way that such a gross alteration of the records 



12 



U.S. Navy Medicine 



could have been successfully defended in court. 

Any alteration of a medical record, no matter how in- 
nocently undertaken, can be turned into something 
ominous by a discerning cross-examiner. Alteration of 
the record raises the implication that there is wrong- 
doing. If the claimant is ever able to bring to the atten- 
tion of the court the fact that the medical record has 
been altered, the value of the claim increases sub- 
stantially. 

What should one do if a record needs changing? If 
one feels that an entry in the record must be changed, a 
simple thin line should be drawn through the entry and 
the correction or change made, initialed, and dated, so 
that everyone will know who made the change, when it 
was done, and what the original entry was. An explana- 
tory note should then be added in the progress notes. A 
note is preferable to "covering up" a record. Some- 
times an erroneous order may require redoing, but it 
should not appear that someone is trying to cover up or 
hide something. 

OTHER PROBLEMS 

In the military medical sector, the physician should 
not forget that patients and their families have ready 
access to their records. They can and do add extraneous 
comments regarding diagnosis, treatment, and what 
they interpret as inadequacies in their care. One should 
watch especially for unsigned entries, entries written in 
the margin, those with frequent gross spelling errors, 
and those that use lay terminology rather than appro- 
priate medical language. For example, this entry was 
found in outpatient progress notes, its date correspond- 
ing to a time when the patient was hospitalized, and its 
remarks referring to a fall from bed and an associated 
head injury the patient claimed to have suffered: 

Patient fell out of bed AM-heavely sedated No guard rails on bed. Big 
lump on base of sekul head. Left shauder and back hurt 1 leg grossly 
buersed black and blue. Complained of pain Guard rails were put 
on bed after patient fell out of bed. X-ray of head. Neg. 

It's easy to guess who inserted this gratuitous com- 
ment in the record, and why. 

This brings us to another moral: Read all pertinent 
entries in the record, whether they are lab slips, X-ray 
reports, or nurses' notes. It's surprising what may be 
found. 

An example is the case of a child brought into an 
emergency room with the usual "URI". The mother 
complained that the child had been febrile for several 
days. The physician ordered a CBC; the result reported 
included a white count of 10,000, with an essentially 
normal differential for a child of the patient's age. And 
that is all the doctor saw. He never noted the hemoglo- 
bin of 2.6 and hematocrit of 7.8. 

Two days later, the patient was brought back, essen- 
tially DO A. At postmortem, the child was found to have 
died of overwhelming pneumonia, with hypoplastic 



erythroid elements in the bone marrow and no stainable 
iron. It's possible that this death could have been pre- 
vented had the doctor looked at the entire lab report. 

Another example involved a military dependent 
being treated at an outlying dispensary for upper respi- 
ratory symptoms. A chest X-ray of the child was read as 
suggestive of miliary tuberculosis. But the doctor who 
ordered the film and received the report just stuck it in 
his bottom desk drawer while he prepared to go on a 
month's leave. No one else knew of this diagnosis. 

Three weeks later, the child developed a headache, 
became lethargic, and was hospitalized. Results of a 
spinal tap were somewhat confusing. By the time a 
repeat chest X-ray had been taken and read, a bony 
lesion had developed and was seen to cross the epiphy- 
seal plate in the proximal humerus. 

Antituberculous therapy for the tubercular meningi- 
tis was not begun until 24 hours after admission. The 
child never recovered. Whether he would have survived 
had the diagnosis of tuberculosis been previously com- 
municated and the disease treated earlier is impossible 
to say. But the government could not prove that death 
was inevitable in any event, and so it settled the claim. 

All progress notes should be written in a timely man- 
ner. Operative reports, particularly, should be dictated 
as soon as possible, especially if the surgery is com- 
plex, involved, or long, or if complications ensue. It is 
difficult, if not impossible, to defend a malpractice suit 
alleging negligent performance of surgery where the 
typewritten operative note was dictated six months 
after the procedure was performed and reads like a 
textbook, describing no complications or problems. 
Progress notes, handwritten two or three weeks after 
the procedure, may give contradictory information and 
may describe results of intra-operative inadvertencies, 
errors, or difficulties. These are knotty problems for the 
defense counsel to reconcile. Recommendation: Settle 
out of court. 

The progress notes of the treating physicians should 
present a logical, chronological development of the pa- 
tient's course, i.e., diagnosis, treatment, response to 
treatment, and any alteration in the therapeutic plan. 
Sometimes physicians get bored with writing "status 
quo," day after day, for a patient who may be treated 
and followed over a long course with little apparent 
change from one day to the next. But the failure to 
make some notation may create a problem, as in this 
instance of the lack of progress notes for 16 days on a 
patient critically ill with a head injury. 

The patient was hospitalized so that he could be 
monitored for signs of a developing subdural hemato- 
ma. Neurological changes were subtle, and were either 
missed or not looked for. It was impossible to tell 
which, because there were no physicians' progress 
notes and no orders during that time. There was no way 
to prove that the patient had even been seen daily by a 
physician! 

The patient was somewhat dysphasic and occasion- 



Volume 69, April 1978 



13 



ally confused, intermittently complained of chest pain 
and hemoptysis, and occasionally was febrile during 
that interval, according to the nurses' notes. Finally, a 
nurse noted that his ankle was red, swollen, and ap- 
parently tender. She put the patient on bed rest, ele- 
vated the leg, and applied hot packs, telling the physi- 
cians who were "treating" him that she thought he had 
a sprained ankle, A few days later, according to the 
progress notes, one of the physicians became 
suspicious that this might be acute thrombophlebitis 
and requested medical consultation, which confirmed 
the diagnosis and recommended anticoagulation ther- 
apy. 

Heparin was begun, but apparently no thought was 
given to the original problem that had prompted the 
patient's hospitalization. Within a few days, the patient 
became comatose, and studies revealed bilateral sub- 
dural hematomas. Anticoagulation therapy was stopped 
in preparation for surgery. At operation, bilateral burr- 
holes confirmed the presence of two subdural hema- 
tomas, one fresh and the other "old," comparable in 
age to the time of the original injury several weeks be- 
fore. 

Apparently, when anticoagulation was reversed, no 
thought had been given to the patient's thrombo- 
phlebitis or the possibility of pulmonary emboli (or the 
fact that earlier episodes of chest pain, fever, and 
hemoptysis may have been due to such emboli). One 
day postoperatively, the patient awoke, sat up, clutched 
his chest, groaned, and fell over dead from massive 
pulmonary embolization. Had daily, careful observa- 
tions been made and noted in the record, his death 
might have been avoided. 

RECOMMENDATIONS 

Experts in the field of medical records recommend, 
as a minimum, six categories of information for 
records: 
• an exhaustive history; 



• a description, recorded as nearly as possible in the 
patient's words, of the present ailment or injury; 

• a report of physical examination, showing objective 
findings on subjective complaints; 

• a record of diagnostic aids used and any reports re- 
ceived concerning the patient; 

• an impression of diagnosis (when a physician is able 
to form only an impression, in the absence of additional 
diagnostic procedures, he should avoid use of the word 
diagnosis); 

• a record of treatment, including any medication pre- 
scribed, and the procedures recommended or per- 
formed. 

A record of any visit by the patient to the physician 
should be carefully maintained, lest it later be sug- 
gested that the doctor failed to employ due diligence, 
or even that he abandoned the patient. This record 
should document response to therapy, any change in 
diagnostic impression, and any new diagnostic pro- 
cedures to be undertaken. 

Obtaining an adequate written consent to surgical 
procedures or any extraordinary mode of therapy can 
be highly significant. Notations on the medical record 
should be made whenever a patient refuses a diagnostic 
aid, such as X-ray photographs; discontinues treat- 
ment, as when he rejects his physician's recommenda- 
tions; or when, against medical advice, he leaves the 
hospital to which he has been confined. 

At the time of a complaint or trial, the medical record 
may be one's only source of information regarding the 
diagnosis, treatment plan, and final evaluation. 
Keeping carefully prepared, complete, accurate, 
legible, and timely medical records is not an additional 
duty of the physician, but part and parcel of the practice 
of good medicine. It should be an indispensable, no ex- 
ception principle. 

Good medical records bespeak good medical care. 
Sloppy records and sloppy thinking may raise a pre- 
sumption of sloppy medical care. And that is an awfully 
difficult presumption to rebut. 



Hobbyists and Do- It- Yourself ers Beware 



During this season, many hobby- 
ists and do-it-yourselfers are busy 
on projects in their garages and 
basements. Even though recent 
years have seen increasing empha- 
sis on home use of protective equip- 
ment, such as safety goggles, other 
measures are needed. 

Rare is the individual who doesn't 
at some time engage in a home 
project — even such a commonplace 



task as assembling an electronic kit 
or refinishing a piece of furniture. 

But equally rare is the individual 
who recognizes the potential haz- 
ards of some of the materials used 
in such activities: paint thinners and 
strippers, glue, epoxies — in fact, 
the whole array of materials that in 
industry are used under strict sur- 
veillance. 

The person who is provided at 



work with an organic vapor respira- 
tor and a well-ventilated environ- 
ment may go home and ignore pre- 
cautions in his hobby work. 

Probably the most common over- 
sight is failure to ensure adequate 
ventilation. In any case, hobbyists 
should know what materials they 
are working with (read the labels!), 
and take precautions accordingly. 
NEHC Occupational Health Notes 



14 



U.S. Navy Medicine 



Policy 



Safety Tips 



Use of Ethylene Oxide in Hospitals 



CDR John P, Swope, MC, USN 
BUMED, Code 416 



Ethylene oxide (EO) is an almost indispensable 
chemical for sterilization of certain items in hospitals. 
But use of this chemical has brought to light some facts 
indicating that EO may have mutagenic properties. 
Thus it should be used only when other sterilization 
processes would not be effective or practical, and when 
an alternate process would pose similar or more serious 
toxicologic problems. 

The control measures outlined below should help to 
minimize any possible risks to hospital personnel in the 
use of EO. These guidelines were developed by the 
American Society of Hospitals Central Service Person- 
nel of the American Hospital Association, in coopera- 
tion with the Health Industry Manufacturers Associa- 
tion. 

EDUCATION AND TRAINING 

All EO sterilization procedures should be supervised 
by the central service manager or supervisor, or by the 
manager of any other department where such 
equipment is installed and operating. 

All personnel working with EO should be given a 
complete orientation to EO processes, covering not only 
the proper use of the sterilization equipment but also 
the safety factors and hazards involved in use of the 
equipment and the chemical. In addition, an in-service 
training program on the EO sterilization process should 
be conducted and an attendance record kept for each 
employee. 

Because proper functioning of the EO sterilizer and 
aerator is necessary for personnel safety, the equip- 
ment should have regular preventive maintenance, 
supervised by a competently trained individual. (Some 
manufacturers have such programs available.) Records 
should be kept on all gas sterilizer malfunctions and 
repairs. 

INSTALLATION OF EO STERILIZERS 

In order to prevent access to the equipment by un- 
authorized persons, EO sterilizers and aerators should 
be located in a restricted area. They should be installed 



in a room that has 6 to 10 air changes per hour and 
complies with the local building codes. The air should 
be exhausted to the outside, well away from any intake 
ducts. There should be easy access to inspection and 
maintenance components, which should be located in 
well-ventilated areas, and the manufacturer's installa- 
tion instructions should be strictly adhered to. 

No other equipment should be stored in the room that 
accommodates the sterilizer and aerator equipment. 

All tanks of EO should be stored in a special area that 
meets appropriate building codes and gas manufactur- 
ers' temperature specifications. Tanks should not stand 
free, but should be chained to a solid structure. 

PERSONNEL PROTECTION 

Personnel working with the EO sterilizer should wear 
protective gloves when handling items taken directly 
from it. 

When the EO sterilization cycle has been completed, 
the door should remain open approximately 6 inches, 
and items should not be removed for 15 minutes. 

Obviously, all items that have been EO sterilized and 
aerated should be handled as little as possible, and pro- 
longed breathing of vapors should be avoided. 

Accidental, excessive exposure to EO by inhalation 
or skin contact should be reported as an incident to the 
commanding officer of the naval hospital. 

Hospitals should monitor the environment in rooms 
containing EO sterilizers and aerators. Monitoring 
equipment is expensive; however, it is important that 
the atmosphere in which people work be evaluated to 
prevent excessive exposure to EO. 

SUMMARY 

Following these guidelines in the handling of 
ethylene oxide should minimize the hazard to personnel 
working with EO sterilizers and aerators. 

The national debate continues over possible federal 
curtailment of the use of ethylene oxide as a sterilant in 
hospitals. It is imperative that Navy hospitals demon- 
strate and document responsible hospital use of EO. 



Volume 69, April 1978 



15 



Scholars 1 Scuttlebutt 



ACDUTRA at OIS Newport 



Hundreds of students in the health professions will soon be receiving 
Active Duty for Training (ACDUTRA) orders to the Officer Indoctrination 
School (OIS), one of seven schools operated by the Naval Education and 
Training Center at Newport, Rhode Island. 

The six-week ACDUTRA tour at OIS is primarily designed to prepare 
students for their roles as naval officers; however, instruction is also pro- 
vided on the organization and mission of the Navy Medical Department and 
its officer corps— Medical, Dental, Nurse, and Medical Service. 

The classroom curriculum at OIS consists of ten units of instruction. 
Units one through six are known as "core topics" and relate to general 
military and management skills. The remaining four units are called "track 
courses" and relate to subjects with direct application to a specific corps. 
Classes are usually scheduled between 0800 and 1600, Monday through 
Friday, with an hour allotted for lunch. 

Students live in King Hall and share rooms similar to those in college 
dormitories. Three reasonably priced meals a day are served at nearby Ney 
Hall, and there are, in addition, the Commissioned Officers' Club, the 
Recreation Center cafeteria, and the "deli" at the convenience store. Also, 
many fast-food facilities and some fine restaurants are available in the 
community of Newport. 

Recreational facilities for students at OIS include tennis, racket ball, 
volley ball, bowling, sailing, swimming pools, a movie theater, and a li- 
brary. The officers' lounge at King Hall has color television. 

The officer indoctrination course schedule permits off-station free time 
(liberty), provided students have kept up with their academic workload. 
Overnight liberty is authorized on Friday and Saturday nights, but not all 
weekends are free. 

Newport itself is a beautiful old city, located on Narragansett Bay and 
the Atlantic Ocean. It has fine beaches, scenic drives, historic buildings, 
and excellent shopping and dining. Students are encouraged not only to 
visit Newport, but to see historic New England as well. 

Each student scheduled to report to OIS Newport is provided detailed 
information, prepared by the Naval Health Education and Training Com- 
mand, on curriculum, facilities, civilian clothing, uniforms, finances, trans- 
portation, and instructions for reporting. 



OIS Newport (clockwise from top left): Students 
learn techniques of military drill; after-class 
study in King Hall; nurses break for lunch at Ney 
Hall; OIS staff member (third from right) gives 
pointers on sailing; students challenge staff in 
traditional volley ball game before graduation; 
Naval Education and Training Center campus 

16 





Volume 69, April 1978 



Okay, 'Doc', take a deep breath 



NOTAP Corpsman Rating Study Under Way 



HMCM Fred A. Burkhart, USN 

The tables have turned. Hospital 
corpsmen, long accustomed to ask- 
ing their patients what ails them, 
are now themselves under scrutiny. 

It's all happening under NOTAP 
— the Navy Occupational Task Anal- 
ysis Program — which has begun a 
detailed study of the hospital corps- 
man rating. The current study is 
part of a BUPERS project to conduct 
a standardized task analysis of all 
Navy enlisted ratings and establish 
an occupational data bank. 

In its participation in NOTAP, the 
Bureau of Medicine and Surgery 
sees an additional benefit beyond 
accomplishment of the program's 
objectives. Very simply, NOTAP is 
giving the Navy Medical Depart- 
ment a golden opportunity to take a 
long, hard look at the way the Hos- 
pital Corps functions. 

In the past, the corpsman* s role 
has too often been vaguely de- 
scribed in terms that paraphrase 
Gertrude Stein: A hospital corps- 
man is a hospital corpsman is a hos- 
pital corpsman. But recently it has 
been suggested that corpsmen 
should serve only in billets written 
to their technical specialties, at skill 
levels commensurate with their pay 
grades and formal training. 

In fact, the Hospital Corps is a 
community of approximately 23,000 
men and women who provide the 
technical and administrative sup- 
port necessary for delivery of health 
care to the Navy and Marine Corps. 
Many hospital corpsmen's skills 
require special training. And be- 
cause many of these technical skills 
are dissimilar — sharing commonal- 
ity only in providing health care — a 
common training base is hard to 
establish. 

Meanwhile, advances in technol- 
ogy, increasing specialization, con- 
tinuing need to provide support to 
the operating forces, and other real- 
world situations complicate man- 



agement and utilization of the Hos- 
pital Corps. 

NOTAP is an effort to find out 
where the problems really lie and 
come up with practical solutions. 
NOTAP analysts are part of the 
Navy Occupational Development 
and Analysis Center, which has a 
staff of about 80 military and civil- 
ian employees skilled in collecting 
and analyzing occupational data. 

Methods. Basically, NOTAP's 
study of the hospital corpsman rat- 
ing has three phases: 

• observing and interviewing corps- 
men, to collect data that can be 
written into task statements and 
developed into questionnaires; 

• administering task-statement 
questionnaires to selected corpsmen 
and programming their responses 
into usable data for task analysis; 

• conducting task analysis. 
Normally, NOTAP uses a single 

task-statement questionnaire to col- 



lect occupational data for each Navy 
enlisted rating under analysis. But 
it was apparent from the beginning 
that a single questionnaire for hos- 
pital corpsmen would not serve the 
needs of the Navy Medical Depart- 
ment. Therefore, BUMED request- 
ed that each technical specialty be 
reviewed. 

Unable to satisfy that request in a 
single effort, NOTAP personnel co- 
operated to the extent of their 
ability and selected the following 
specialties (with their Navy enlisted 
codes) for initial study: Afloat/Inde- 
pendent Duty (0000, 8402, 8407, 
8425); Field Medical Service (8404); 
Biomedical Equipment Repair 
(8477, 8478, 8479); Radiology 
(8452); Preventive Medicine (8432); 
Ward Corpsmen (0000); Pharmacy 
(8482); Laboratory (8501-8507); 
Aerospace (8406, 8409); Optician 
(8463); Ocular and Otolaryngology 
(8444, 8445, 8446); Operating Room 




With the help of corpsmen like this one, NOTAP will supply important data on the 
changing roles of Hospital Corps personnel. (Photo by PH2 Claudie Bob Johnson II) 



18 



U.S. Navy Medicine 



(8483); Cardiopulmony (8408). 

During Phase 1 , NOTAP analysts 
visited and interviewed hospital 
corpsmen at 39 different com- 
mands. The success of this initial 
phase is attributable to these men 
and women, who enthusiastically 
cooperated in the project by giving 
NOTAP personnel the benefit of 
their knowledge and experience. 

Phase 2 of NOTAP is now under 
way. In late 1977, NOTAP person- 
nel made trips to Norfolk, New 
London, San Diego, and Charleston 
to survey 342 corpsmen serving on 
ships and submarines. This year 
thousands of additional corpsmen 
serving in the billets selected for 
study will be asked to respond to the 
task-statement questionnaire. 

During April and early May, 
NOTAP personnel will be adminis- 
tering questionnaires at Great 
Lakes, 111,; Camp Lejeune, N.C.; 
Jacksonville, Fla.; Oakland and San 
Diego, Calif.; and Charleston, S.C. 

Data collection under Phase 2 will 
continue through this summer, or 
until sufficient data has been gath- 
ered to permit task analysis. Phase 
3, the task analysis itself, may begin 
as early as this spring for some 
specialties, and will continue 
through 1978. 

Impressions. What NOTAP will 
finally reveal cannot, of course, yet 
be known; however, impressions 
gained from Phase 1 indicate that 
the roles and responsibilities of hos- 
pital corpsmen are changing and 
sometimes unclear. But this should 
not be surprising. As methods of 
providing health care change, those 
who deliver that care must adapt 
and follow the trends. 

U. S. Navy Medicine will continue 
to report on the progress of this im- 
portant project. Meanwhile, ques- 
tions or comments on NOTAP may 
be addressed to HMCM Fred A. 
Burkhart, HM1 David B. Crockett, 
or HM1 Louis C. Gerecz (assigned 
to the project as technical advisors) 
at the Bureau of Medicine and Sur- 
gery (Code 34), Washington, D.C. 
20372; telephone: Autovon 294-4682 
or 288-4626; Commercial (202) 254- 
4682 or 433-4626. 



Letters 



COVER DISLIKED 

I think the December 1977 cover 
is objectionable and in very poor 
taste with bad connotations. It 
seems to me that in our society with 
its many drug problems of today, 
you could have made a better choice 
for U.S. Navy Medicine. 

CAPT W.L. Skinner, MC, USN 

Chief of Surgery 

NRMC Charleston. S.C. 

We're sorry you disliked the De- 
cember cover, which was selected to 
highlight the article in that issue on 
BUMED's participation in the Na- 
tional Immunization Initiative. — Ed. 



INFANT IMMUNIZATIONS 

While reading the December 
1977 issue, I noticed in the article 
"BUMED Backs Immunization Ini- 
tiative" that you published a picture 
of a nurse administering an injec- 
tion to an infant in the gluteal 
region. 

I am absolutely amazed that this 
practice exists — apparently in a 
military organization — and that it 
was published in a medical publica- 
tion. Injections should not be ad- 
ministered to infants in the gluteal 
region due to the greater possibility 
of hitting the sciatic nerve and 
causing paralysis. Every nursing 
school that I know of teaches its 
students that the more appropriate 
and safer place for injections in 
infants is into the muscles of the 
leg. I would hope that closer evalua- 
tion and supervision is given to 
those responsible for the adminis- 
tration of medications to infants. 

LT K.J. Ivancic, NC, USNR 

Charge Nurse, Pediatric Ward 

NNMCBethesda. Md. 

In their product inserts, Wyeth 
Laboratories suggest all doses of 
DPT be injected intramuscularly, 
"preferably into the mid-lateral 
muscles of the thigh or deltoid." 

Ross Laboratories' series of 
Nursing Inservice Aids also favors 



the midanterior muscle of the thigh 
as the prime site of IM injection. 

The fourth edition of Dorothy R. 
Marlow's Textbook of Pediatric 
Nursing recommends the vastus 
lateralis as the primary site of injec- 
tion for infants "because it is well- 
developed at birth and because it is 
not close to major nerves and ves- 
sels." 

The sixteenth edition of Pediat- 
rics, edited by Abraham M. Ru- 
dolph, states: "The large muscle 
mass of the lateral thigh is the pre- 
ferred site, but the deltoid is suit- 
able in older children. Some physi- 
cians continue to administer these 
in the buttock in spite of the known 
risk of damage to the sciatic nerve." 

We have always followed these 
recommendations and give all infant 
IM injections in the midanterior 
muscle of the thigh. We feel clarifi- 
cation of this error should appear in 
your publication to avoid future con- 
fusion. 

HM2P.E. Nast, USN 

Senior Corpsman 

Pediatric and Immunization Clinic 

NRMC Camp Pendleton, Calif. 

LT Ivancic and HM2 Nast are ab- 
solutely right. The photograph they 
refer to was not a Navy picture, but 
was graciously provided by the 
Center for Disease Control. The 
editors should, however, have 
looked at it more carefully. — Ed. 



Your letters help us keep US 
Navy Medicine responsive to 
your needs. Send letters to: 
U.S. Navy Medicine 
Department of the Navy 
Bureau of Medicine and 

Surgery 
23rd and E Streets NW 
Washington, D.C. 20372 



Volume 69, April 1978 



19 



Education & Trainin 



a 



AFRRI/NNMC 



Nuclear Weapons Effects Course 

CDR Richard F. Kiepfer, MC, USN LTC John T. Mason III, USA LT COL Lawrence F. Winans, USAF 



With the proliferation of nuclear 
material throughout the world, 
there is an ever-increasing possibil- 
ity that ionizing radiation injuries 
may occur. 

Moreover, although the SALT 
negotiations may eventually reduce 
or even eliminate the possibility of a 
nuclear war, until that time the 
threat of the "mushroom cloud" is 
ever present. Because of this, and 
because nuclear material is used 
throughout the Armed Forces, mili- 
tary medical personnel must be pre- 
pared to treat radiation casualties in 
both peacetime and wartime situa- 
tions. Although the condition of the 
casualty may be the same in either 
case, the circumstances surround- 
ing his exposure will have great im- 
pact on his medical treatment. 

Peacetime. Peacetime exposure 
to ionizing radiation, other than 
diagnostic and therapeutic, may 
come from a variety of sources. 
Generally, it will be accidental, but 
there is also a possibility that it may 
occur through the intentional acts of 
terrorists. In either case, a military 
medical facility will be treating cas- 
ualties under peacetime conditions 
(i.e., the facility will be fixed and 
relatively well staffed), with no ma- 
jor restrictions on national commu- 
nications and logistic capabilities. 



CDR Kiepfer is Head of the Nuclear Medi- 
cine Branch. National Naval Medical Center. 
Bethesda, Md. 20014. 

LTC Mason is Education Program Coordi- 
nator, and LT COL Winans is Chief of the 
Nuclear Sciences Department, Armed Forces 
Radiobiology Research Institute, Bethesda, 
Md, 20014. 



Accidental exposures may occur 
as a result of nuclear reactor prob- 
lems, mishandling of radionuclides, 
difficulties arising during transpor- 
tation of radioactive material, or 
similar mishaps. Generally, such 
exposures would result in injuries of 
varying degrees to only a few 
people in a localized area. The prob- 
ability that several accidental ex- 
posures would occur within a short 
time is remote; therefore, it is suffi- 
cient to prepare for isolated events. 

Exposures resulting from acts of 
terrorists will come only from indi- 
viduals who are so involved in some 
cause that the value of human life is 
insignificant to them. Fortunately, 
these individuals appear to be few. 
This paucity — and the safety and 
security procedures instituted for 
handling radioactive material — 
make this intentional exposure a 
remote possibility. Thus one again 
arrives at preparation for isolated 
events. 

Since these intentional expo- 
sures, if they occur in peacetime, 
must be treated as accidents, the 
entire peacetime approach is 
oriented toward preparing for acci- 
dental exposures. The civilian medi- 
cal community has been planning 
for such contingencies, especially 
where radiation sources are geo- 
graphically concentrated. The Radi- 
ation Emergency Assistance Cen- 
ter/Training Site (REAC/TS), at 
Oak Ridge, Tenn., is a national 
center for the study of human radia- 
tion exposure. This agency can treat 
radiation accident cases. It also con- 
ducts national training courses in 



handling such cases and acts as the 
U.S. national repository of informa- 
tion on radiation accidents. 

Wartime. Wartime exposure to 
ionizing radiation would probably 
result from intentional nuclear 
weapon detonation. There might be 
cases of accidental exposure, but a 
military medical facility required to 
treat the accident casualties would 
be operating under wartime condi- 
tions, i.e., it would be semimobile, 
relatively understaffed, and re- 
stricted as to communications and 
logistic capabilities. Under these 
conditions, accidental cases would 
be treated in the same manner as 
intentional exposures. 

In a nuclear war, both accidental 
and intentional exposures would be 
of more concern to the military than 
to the civilian doctor, since most 
such exposures would occur (it is to 
be hoped) in the war zone. Of 
course, if the conflict were to take 
place in the United States, the civil- 
ian medical community would also 
be affected and would be forced to 
function in somewhat the same way 
as the military. 

The training problem. In the 
three services, training exists for 
military medical professionals on 
the overall effects of nuclear weap- 
ons and the political doctrines that 
may lead to their use. These profes- 
sionals also receive instruction in 
treating trauma and mass casual- 
ties. But there has been no exten- 
sive course for military doctors on 
the detailed radiobiological effects 
of radiation, associating these ef- 
fects with the overall conditions ex- 



20 



U.S. Navy Medicine 



pected in a nuclear war (or other 
combined stress-and-injury situa- 
tion). 

This detailed instruction is neces- 
sary if the physician is to do more 
than simply treat the symptoms of a 
patient exposed to radiation. More- 
over, continuing instruction for the 
military medical corps is required, 
since constant turnover leads to loss 
of the expertise of trained person- 
nel. 

Recognizing these needs, in 1976 
the Surgeons General of the Army, 
Navy and Air Force asked the 
Armed Forces Radiobiology Re- 
search Institute (AFRRI), Bethesda, 
Md., to assist in developing a pro- 
gram to increase knowledge of 
nuclear weapons effects at all levels 
throughout the medical service. 
(The Surgeons General and the 
Director, Defense Nuclear Agency, 
comprise the Board of Governors for 
AFRRI.) 

Course development. In Phase I 
(Fiscal Year 1977), the first step was 
to determine what should be taught 
in the new program and who the 
students should be. A short curricu- 
lum was prepared, covering the es- 
sentials of nuclear weapons and 
their effects. The initial course was 
limited to eight lecture periods, pre- 
pared and presented entirely by 
AFRRI personnel. A notebook con- 
taining material covered in the lec- 
tures was prepared for the students. 

After this short course had been 
presented to the AFRRI staff, it was 
determined that the primary audi- 
ence should be medical personnel 
having some familiarity with radia- 
tion. In the event of nuclear war, 
radiologists and nuclear medicine 
specialists probably would be call- 
ed, because of their expertise, to 
advise on radiation injury. Of 
course, the skills of the entire medi- 
cal community would be needed, 
and the radiation specialists would 
have to share their knowledge of 
nuclear weapon effects with the 
general internists and surgeons 
(who have less background in basic 
nuclear physics). Therefore, the 
selected primary audience for the 
new Nuclear Weapons Effects 



Course was to be nuclear medicine 
students. 

The only military short course in 
nuclear medicine is conducted twice 
annually at the National Naval Med- 
ical Center (NNMC) in Bethesda, 
Md. It lasts approximately two 
months. The new AFRRI course on 
nuclear weapons effects was in- 
jected into NNMC's Nuclear Medi- 
cine Course, primarily as part of the 
radiobiology instruction. 

Condensed portions of the nu- 
clear weapons effects lectures were 
also given to students from the Uni- 
formed Services University of the 
Health Sciences (USUHS), cadets of 
the United States Army Military 
Academy, and medical resident 
physicians from Walter Reed Army 
Institute of Research and NNMC. 

Another avenue of instruction 
was opened by development of TV 
tapes for the skeletal lectures of the 
course. 

In Phase II (Fiscal Year 1978), the 
Nuclear Weapons Effects Course 
was expanded to 14 lecture periods, 
including more material on the bio- 
logical effects of nuclear weapons 
and a period on the threat posed to 
the United States. For students in 
the NNMC Nuclear Medicine 
Course and USUHS, modifications 
were made in content and level of 
presentation. Agencies outside 
AFRRI were asked to assist, and 
they contributed significantly to the 
program. 

In preparation for Phase III (Fis- 
cal Year 1979), the Nuclear Weap- 
ons Effects Course is again being 
expanded, and with this expansion 
it will constitute one week of in- 
struction as part of NNMC's Nu- 
clear Medicine Course. (The lecture 
series developed during Phase II 
will continue to be presented to 
USUHS students.) Extensive out- 
side support has been requested for 
new lectures not within AFRRI's 
area of expertise, and funding 
support and AMA credits have been 
obtained. Developments after FY 
1979 will depend on acceptance of 
Phase III and feedback from those 
in the field. 

As now envisioned, the course 



will consist of 34 lecture periods of 
50 minutes each, on the topics listed 
in the table accompanying this 
article. Instructing agencies, in ad- 
dition to AFRRI, are: U.S. Army 
Nuclear and Chemical Agency 
(USANCA), Ft. Belvoir, Va.; Uni- 
formed Services University of the 
Health Sciences (USUHS), Bethes- 
da, Md.; U.S. Army Academy of 
Health Sciences (USAAHS), Ft. 
Sam Houston, Tex.; Walter Reed 
Army Institute of Research 
(WRAIR), Washington, D.C.; U.S. 
Army Ordnance and Chemical Cen- 
ter and School (USAOCCS), Aber- 
deen Proving Ground, Md.; and 
Radiation Emergency Action Cen- 
ter/Training Site (REAC/TS), Oak 
Ridge, Tenn. 

The course is being planned for 
October 1978 and again for January 
1979. It will be conducted at AFRRI, 
on the grounds of NNMC. 

Students in the AFRRI/NNMC 
course must be either active-duty 
M.D.'s, specializing in nuclear 
medicine or radiology, or persons 
with a graduate degree in a related 
field. They must have a "secret" 
security clearance. 

AFRRI will provide funding for 
travel and one week's per diem 
allowance to 60 students — 10 Army, 
10 Navy, and 10 Air Force students 
in each of the two classes. Un- 
funded additional students may be 
accepted from each service for each 
class, on a first-come-first-served 
basis. 

The course is accepted by the 
American Medical Association for 
Category I Hour for Hour Continu- 
ing Education Credit. 

Application. Prospective students 
may apply through normal training 
channels. Information may be ob- 
tained from CDR Richard F. Kiepf- 
er, MC, USN, Head, Nuclear Medi- 
cine Branch, National Naval Medi- 
cal Center, Bethesda, Md. 20014 
(Autovon 295-0208; Commercial 
202-295-0208); or LTC John T. 
Mason III, USA, Education Program 
Coordinator, Armed Forces Radio- 
biology Research Institute, Bethes- 
da, Md. 20014 (Autovon 295-0227; 
Commercial 202-295-0227). 



Volume 69, April 1978 



21 



AFRRI/NNMC NUCLEAR WEAPONS EFFECTS COURSE, FY 1979 



SUBJECT 



LECTURE 
PERIODS* 



INSTRUCTING 
AGENCY 



Introduction: 



Introduction; History of Nuclear Weapons 1 

Warsaw Pact Nuclear Concepts (SECRET) 1 

Tactical Commanders Concept of Nuclear War 1 

Nuclear Weapon Phenomenology 2 

Biomedical Effects: 

Blast and Thermal Effects of Nuclear Weapons 1 

Radiation Biology 4 

Early Cardiovascular Decrement of Personnel 

in Nuclear Weapon Environments 1 

Early Behavioral Performance Decrement of Personnel 

in Nuclear Weapon Environments 1 

Psychological Effects of Nuclear Operations 1 

Low Radiation Dose Effects 1 

Combined Radiation Injury with Chemicals 1 

Non-Ionizing Radiation Effects 1 

Impact on Medical Service: 

Medical Operations in a Nuclear War 1 

Estimation of Casualties 1 

Patient Management Techniques 1 

Diagnosis and Treatment of Nuclear Weapon Casualties . . 1 



AFRRI 

USANCA 
USANCA 
AFRRI 



AFRRI 

AFRRI 

AFRRI 

AFRRI 

USUHS 

USAAHS 

AFRRI 

AFRRI 



USAAHS 
USAAHS 
USAAHS 
WRAIR 



Detection and Protection: 



Radiation Instruments 1 

NBC Warning and Reporting 1 

NBC Predictions 1 

Operations in Fallout 1 

Miscellaneous : 

Nuclear Reactors 1 

Nuclear Material Accidents 1 

Research Problems 1 

Nuclear Exercise 7 



AFRRI 
USAOCCS 
USAOCCS 
USAOCCS 



AFRRI 
REAC/TS 
AFRRI 
USAAHS 



* 50 minutes each 



U.S. Navy Medicine 



Professional 



A Report of Intractable Epistaxis 

CDR Alan D. Kornblut, MC, USNR CDR Raymond A. Kempf, MC, USN LCDR Frank S. Curto, Jr., MC, USN 



Epistaxis, or nosebleed, is a relatively common 
medical problem that can result from a wide variety 
of causes. Most nosebleeds are due to trauma (which 
may be self-inflicted from "picking"), or they may 
occur spontaneously if the nasal mucosa dries and 
cracks, with subsequent bleeding. This latter cause 
is particularly significant in hypertensive patients or 
in patients with a deformed nasal septum. Occasion- 
ally, however, nosebleeds may be associated with 
neoplastic growths or with use of medications which 
have anticoagulant properties. 

Usually, nosebleeds can be controlled by relatively 
simple supportive measures, such as reassurance, 
rest, and judicious placement of intranasal cotton 
pledgets for hemostasis. When these measures fail, 
more aggressive therapy becomes necessary. Treat- 
ment may include firm anterior or posterior nasal 
packing, prophylactic antibiotics to prevent second- 
ary paranasal sinus infection, and sedatives or tran- 
quilizers to control any apprehension experienced by 
the patient (1-3). Uncommonly, transfusions (partic- 
ularly with fresh frozen plasma or fresh blood), sup- 
plemental medications (such as phytonadione and 
epsilon-aminocaproic acid) to effect coagulation, and 
even selective surgical ligation of vessels to the nose 
may be required to prevent exsanguination (4-6"). 
These measures are described in the following re- 
port, which typifies management of the complicated 
patient with nasal bleeding and describes some of 
the many problems that may be encountered in ef- 
fecting control. 

PATIENT REPORT 

The patient was a 46-year-old white housewife, the 
dependent wife of a retired Marine Corps chief war- 

Drs. Kornblut and Curto are with the Department of Otolaryn- 
gology, and Dr. Kempf is with the Department of Hematology, 
National Naval Medical Center, Bethesda, Md. 20014. 



rant officer. On 13 April 1977 she was transferred 
from Naval Regional Medical Center, Camp Lejeune, 
N.C., to the National Naval Medical Center, Bethes- 
da, Md., for care of intractable epistaxis. 

The patient had undergone mitral commissurot- 
omy in 1956 as treatment for mitral stenosis which 
had followed rheumatic heart disease in childhood. 
She did well until 1971 when mitral valve replace- 
ment became necessary. This procedure was compli- 
cated by atrial fibrillation with a slow ventricular 
response. A permanent transvenous cardiac pace- 
maker was placed; digitalization was also required 
and maintained. 

In March 1977, cardiac surgery again became 
necessary and a tricuspid porcine valve was inserted 
at the National Naval Medical Center. Following 
surgery, anticoagulation with Coumadin was begun. 
The patient was then discharged from hospital care 
and did well at home until the first week of April 
1977, when she began to experience recurrent nose- 
bleeds. 

Coumadin was stopped, and anterior nasal 
packing was placed. When bleeding persisted, she 
was admitted to NRMC Camp Lejeune, where the 
nasal packs were immediately readjusted and fresh 
frozen plasma was given with parenteral phytonadi- 
one (vitamin Ki). When bleeding continued, whole 
blood transfusion became necessary. 

It was then believed that better control of bleeding 
could be realized with selective transantral ligation 
of the left internal maxillary artery. This surgery was 
performed on 11 April, without complications. A 
Foley catheter was placed in the left maxillary 
antrum for wound hemostasis, and nasal packing 
was maintained. However, when bleeding con- 
tinued, the patient was transferred to the National 
Naval Medical Center for further care. At the time of 
her transfer she had received approximately 13 units 
of transfused blood. 



Volume 69, April 1978 



23 



Physical examination on admission to NNMC 
showed the patient to be markedly apprehensive and 
in acute distress. Although the left antral catheter 
and nasal packs were still in place, bloody discharge 
oozing from the nose and throat required constant 
suction. The patient was receiving blood transfusion 
at the time of admission, but her vital signs had 
remained stable (pulse rate 75 beats per minute; 
blood pressure 158/90). Prominent left infraorbital, 
maxillary and buccal edema and ecchymosis, with 
soft tissue hematoma, were present and were com- 
patible with recent surgery on the left maxilla. Mul- 
tiple integumental petechiae were found over the 
back and arms, and a soft tissue hematoma was un- 
covered over the medial aspect of the left ankle. In 
addition, the patient had right thoracotomy and 
median sternotomy scars, as well as a left upper 
abdominal scar consistent with venous pacemaker 
implantation. Auscultation of the heart revealed a 
regular sinus rhythm, but with a low-pitched ejection 
murmur that was best heard at the cardiac apex and 
that radiated to the left sternal border. Hepatomeg- 
aly was also found on palpation of the abdomen. 

Admission laboratory studies showed a hemoglo- 
bin level of 11 gm/100 ml and a hematocrit level of 
32.2%. Serum electrolytes, blood urea nitrogen, and 
creatinine levels were within normal limits. 
However, total bilirubin level (2.7 mg/100 ml) was 
elevated, as were serum alkaline phosphatase (90 
mU/ml) and lactic dehydrogenase (291 mU/ml) 
levels. Total serum protein level was 6.2 gm/100 ml, 
with 2.5 gm/100 ml albumin. Platelet count, pro- 
thrombin time, and partial thromboplastin time were 
within normal limits. 

In view of the persistent bleeding from the nose 
and throat, it was felt that angiography on admission 
might help define the patient's site of bleeding and 
facilitate further care (7). The procedure, completed 
with some difficulty, demonstrated that primary 
bleeding was from the posterior oropharynx through 
an anomalous ascending pharyngeal artery that orig- 
inated from the right external facial artery (Figures 1 
and 2). Consideration was given to possible gelfoam 
embolization, but since the patient had by then re- 
ceived almost 20 units of blood, further delay in 
definitive therapy was thought to be unsafe. 

Consequently, emergency ligation of the right 
external carotid artery was performed under local 
anesthesia. The procedure included selective ligation 
of both the external facial and ascending pharyngeal 
arteries. Bleeding was immediately controlled, but 
nasal and antral packs were left in place to minimize 
further mucosal trauma. 




FIGURE 1. Left external carotid angiogram. Surgical clips oc- 
cluding the internal maxillary artery (IMA) are circled 

The patient's subsequent hospital course was 
stormy. Following surgery the patient had fever 
spikes of 103° F, which were related to pneumonitis 
from aspiration of blood as well as to possible 
sinusitis as a consequence of nasal packing. Cepha- 
lexin was given initially, in addition to pulmonary 
physiotherapy. After consultation with the Thoracic 
Surgery and the Infectious Disease Services, genta- 
mycin and oxacillin were also given, with resolution 
of fever. 

Nasal and antral packs were removed safely within 
five days of surgery. However, other problems oc- 
curred. On 16 April, an S3 cardiac murmur was de- 
tected, and subsequent chest roentgenograms were 
believed to be compatible with early congestive heart 
failure. Digitalization with digoxin was maintained, 
but parenteral furosamide (40 mg/daily) was added 
for diuresis and control. 

A sterile wound hematoma subsequently devel- 
oped in the right side of the patient's neck, but 



24 



U.S. Navy Medicine 




FIGURE 2. Right carotid angiogram. Bleeding site in the 
pharynx (circled) originates from collateral vessels derived 
from the ascending pharyngeal (APA) and external facial 
arteries (EFA) 



cleared spontaneously. Although admission clotting 
studies had been normal, repeat studies on 18 April 
uncovered a markedly elevated partial thromboplas- 
tin time (52.2 seconds vs. a control of 29.7 seconds). 
Fibrinogen level was 420 gm/100 ml. Platelet counts 
and prothrombin time were both normal. 

Integumental petechiae were again noted, with 
increased capillary fragility. A consultation was then 
obtained with the NNMC Hematology Service. 
Factor analysis and repeat coagulation studies were 
performed, and a clotting pattern was uncovered 
that was compatible with localized fibrinolysis. It 
was then suspected that the hematoma that had per- 
sisted in the left maxillary soft tissues was releasing 
fibrin split products into the blood, causing abnormal 
partial thromboplastin and thrombin times. The 
hematoma was therefore evacuated and a Foley 
catheter used to control wound bleeding. 



Because of the high-output cardiac failure and 
sepsis the patient had experienced during her hos- 
pitalization, it was feared that the prosthetic cardiac 
valves might be compromised. Ketrograde cardiac 
catheterization was performed on 9 May through a 
left antecubital vein. No significant flow gradients 
were found, which indicated that the prostheses 
were functioning normally. After this procedure, 
however, an antecubital hematoma developed and a 
spontaneous right inguinal hematoma was also un- 
covered. Both hematomas were evacuated without 
complication. 

Further clotting studies revealed that an unchar- 
acterized antithrombin factor had developed, with a 
positive indirect Coombs (anti-Kell) test. A persist- 
ent hypergammaglobulinemia (4.6-4.8 mg/100 ml) 
was also noted, which was believed to represent a 
reactive pattern alone. 

The rest of the patient's hospital course was sup- 
portive and without additional incident. Outpatient 
care began on 26 May. Discharge medications in- 
cluded digoxin and diazepam (as a tranquilizer), as 
well as iron and vitamin supplements. The patient 
has done well since her discharge, although moder- 
ate elevation of the partial thromboplastin time 
persists. 

SUMMARY 

This report of intractable epistaxis describes some 
of the difficulties encountered in the clinical manage- 
ment of this problem, and outlines procedures that 
might be needed to achieve satisfactory control. 
Although many measures have been employed to 
treat problem patients with nasal bleeding, the basis 
for effective therapy still remains careful, systematic 
evaluation. 

REFERENCES 

1. Call WH: Control of epistaxis. Surg Clin North Am 
49:1235-1247, 1969. 

2. el Bitar H: The etiology and management of epistaxis. A 
review of 300 cases. Practitioner 207:800-804, 1971. 

3. Pearson BW: Epistaxis. Postgrad Med 57(6): 116-119, 
1975. 

4. Petruson B: Epistaxis. A clinical study with special refer- 
ence to fibrinolysis. Acta Otolaryngol [Suppl] (Stockh) 317:1-73, 
1974. 

5. Rosnagle RS, Yanagisawa E, Smith HW: Specific vessel 
ligation for epistaxis and survey of 60 cases. Laryngoscope 83: 
517-525, 1973. 

6. ShaheenOH: Arterial epistaxis. J Laryngol 89: 17-34, 1975. 

7. Taylor PH, McCall IW: The use of angiography in a case of 
recurrent epistaxis after multiple arterial ligations. Br J Surg 61 : 
721-723, 1974. 



Volume 69, April 1978 



Survey of Tarsal Coalitions Found 
at MCRD Parris Island, S.C. 



LT John J. Malone, MSC, USN 



Tarsal coalitions have been observed for more 
than 200 years. In 1879, Anderson (I), an anatomist 
from Ireland, described bilateral talonavicular coali- 
tion, although the significance of this deformity was 
not known. In 1921, Slomann {2) associated coali- 
tions with "peroneal spastic flatfoot." But it was not 
until 1948 that Harris and Beath (3) recognized that 
the rigid valgus foot was not due to peroneal spasm, 
but to congenital fusion. 

The clinical significance of tarsal coalitions is that 
they are associated with symptomatic flatfeet. The 
condition is a congenital anomaly affecting the foot 
and is inherited by means of an autosomal dominant 
trait. The etiology is a matter of conjecture, but some 
theories have advanced, e.g., congenital failure of 
primitive mesenchyme, trauma, and infection. 

The term "coalition" denotes a fusion or an 
ankylosis of a joint, prohibiting normal biomechani- 
cal motion and thus producing a rigid flatfoot. The 
rigidity is the factor that distinguishes this deformity 
from the more prevalent, flexible pes planus. 

Coalitions, which are referred to in literature as 
"bars" or "bridges," may be classified into three 
types, depending on the histological union: (1) osse- 
ous (synostosis), (2) cartilaginous (synchondrosis), 
and (3) fibrous (syndesmosis). All three produce the 
same type of rigid foot deformity. Anatomically, they 
may manifest themselves in any of the seven tarsal 
bones, but they are most commonly found at the 
talocalcaneal or calcaneonavicular joints. 

CLINICAL FINDINGS 

The pathognomonic sign of a coalition is the dimi- 
nution or absence of inversion -eversion motion at the 
subtalar (talocalcaneal) joint or the Choparts joint 
(between the talocalcaneal and the lesser tarsus). 

On clinical examination, it must be established 
whether the frontal plane motion is originating from 
the intrinsic joints of the foot or from the joint 
created by the ankle mortise and the talus. To accu- 
rately examine the range of motion of the subtalar 

LT Malone is a podiatrist in the Department of Orthopedics, 
Branch Dispensary, Naval Hospital Beaufort, MCRD Parris 
Island, S.C. 29905. 



joint, the foot should be placed in a neutral position 
and slightly dorsiflexed. This prevents frontal plane 
motion at the ankle joint by locking the wide troch- 
lear surface of the talus in the ankle mortise. 

Often there is a diffuse, nonpitting edema and 
tenderness on the dorsum of the foot. The pain is 
exacerbated by passive inversion of the foot, and is 
caused by compensatory strain on other joints of the 
foot. Although the peroneal muscles will look as 
though they are in spasm, in most cases this is not 
spasm, but a tautness that represents a physiological 
shortening as a result of the valgus deformity. 
Therefore, the term "peroneal spastic flatfoot" is a 
misnomer and is not to be associated with coalitions. 

The patient usually has a marked, abducted, duck- 
like gait, almost as if he were walking on the insides 




Normal" foot. Note joint space between talus and os calcis 




Obliteration of joint space between tat us and os calcis. Note 
prominent osteophyte at head of talus 



U.S. Navy Medicine 



of his ankles. His toe-off will be apropulsive, since he 
lacks the ability to supinate his foot at this critical 
point of walking. When the patient is examined in a 
full weight-bearing stance, the heel will be in valgus 
position and will fail to reduce in a non-weight-bear- 
ing stance. 

Tarsal coalitions are not exclusive of sex or age, 
but are found primarily in males in the second 
decade of life, and may be bilateral. Patients with 
coalitions may or may not be symptomatic, depend- 
ing on factors such as lifestyle and occupation. Often 
patients have asymptomatic coalitions until such 
factors as excessive use of their feet or trauma pre- 
cipitate an episode of podalgia. 

RADIOGRAPHIC FINDINGS 

The subtleties of radiographic techniques can 
make identification of coalitions a challenging task, 
even for the seasoned clinician or radiologist. The 
position of the patient's foot and the angle of the 
tube may produce overlapping of bone, presenting a 
"pseudo-coalition" on the X-ray film. 

In order to avoid a diagnostic error, several 
oblique views of the foot should be obtained. Besides 
the standard views, a coalition or an axial view is 
needed to rule out a fusion of the middle facet at the 
sustentaculum tali of the talocalcaneal joint. If radio- 
graphs are inconclusive, tomograms and arthro- 
grams of the suspect joint may aid in the diagnosis. 

On the lateral view of the foot, one sees an oblit- 
eration of the joint space between the talus and cal- 
caneus, with dorsal lipping of the talus— in actuality, 
an osteophyte resulting from arthritic changes. 
There may also be a broadening of the posterior 
process of the talus. On examination of the medial 
oblique view, there will be no evidence of a joint be- 
tween the anterior process of the calcaneus and the 
navicular. Instead, there will be an osseous bridge 
between the two bones. 

Cartilaginous and fibrous coalitions are not as 
easily identified as osseous bars. The clinician must 
look for radiographic clues such as irregularities and 
obscure cortical margins. In these cases, there must 
be a careful correlation between radiographic and 
clinical findings. 

TREATMENT 

Treatment varies with the degree of symptomatol- 
ogy and whether the condition is acute or chronic. 
Usually there is some immediate abatement of pain 
with rest, contrast baths, and analgesics. Rigid 



appliances or special footgear may be of palliative 
value. Intra-articular injections of insoluble cortico- 
steroids may be useful in alleviating discomfort from 
cartilaginous and fibrous bars. In an acute episode, 
immobilization in a short leg walking cast may be the 
treatment of choice. 

Surgical excision of a bar has no place in the treat- 
ment of painful coalitions because of the secondary 
arthritic changes that will have occurred in other 
joints of the foot. In recalcitrant cases an arthrodes- 
ing procedure may be in order, such as a triple ar- 
throdesis or Grice procedure. 

INCIDENCE OF PATHOLOGY 

In 1948, Harris and Beath {3) } performing routine 
physical examinations on 3,600 Canadian Army en- 
listees, found 72 patients with peroneal spastic flat- 
foot. In 1951, Vaughan and Segal (4), while in the 
U.S. Army, examined 2,000 patients with painful 
feet and found 21 with radiographic evidence of 
tarsal coalitions. 




Example of osseous fusion between the calcaneus and the 
navicular (medial oblique view) 




Markedly pronated foot with complete osseous fusion of sub- 
talar joint and dorsal lipping at talonavicular joint 



Volume 69, April 1978 



27 



The Marine Recruit Depot at Parris Island, S.C., 
receives approximately 28,000 recruits a year. There 
are approximately 14,000 recruit visits to the Podia- 
try Clinic per year for various foot and ankle mala- 
dies. In a one-year period (June 1975 to June 1976), 
68 recruits received medical discharges for symp- 
tomatic pes planus. Of that number, 11 showed 
radiographic evidence of tarsal coalitions (see table). 

As is evident from the data collected, the calca- 
neonavicular synostosis was the most common coali- 
tion seen at our clinic. The age range of the recruits 
with this pathology was 17 to 22 years. The majority 
of these patients denied having any significant foot 
problems prior to entering the service and were 
active in high school athletics and sports. One pa- 
tient's coalition had been previously diagnosed by a 
civilian doctor, who had surgically excised it. 

None of the 11 patients could relate any clear his- 
tory of traumata, activities, or events that might 
have precipitated their foot pain. In most cases the 
pathology appeared gradually and insidiously, 
except in one patient who developed pain in his feet 
after a long forced march. 

Most patients responded satisfactorily to light 
duty and supportive therapy, consisting of crutches, 
strapping, analgesics, and hydrotherapy. Unfortu- 
nately, when these patients were sent back to full 



Tarsal Coalitions in Marine Recruits, One- Year Period 




Coalitions 

Talocalcaneal (synostosis) 
Calcaneonavicular (synostosis) 
Calcaneonavicular (syndesmosis) 
Calcaneonavicular (synostosis) 


No. of Cases 

2 
6 
2* 
1** 



Severe rigid valgus foot deformity— heel markedly everted 

28 



*Both cases were bilateral. 

"*Patient had bar surgically excised prior to his entrance into 
the service. 



duty they became symptomatic and were later medi- 
cally discharged from the service. One patient with a 
diagnosis of bilateral calcaneonavicular synostosis 
did not respond to the usual treatment regimen and 
had to be immobilized in short leg walking casts for a 
period of four weeks. After his four weeks of immo- 
bilization, he was relatively asymptomatic and was 
medically discharged. 

CONCLUSION 

In the examination of symptomatic flatfeet, one 
should be alert to clinical and radiographic findings. 
If there is exquisite pain on supination of the foot, 
and evidence of limitation of motion at the subtalar 
joint on the frontal plane, one should suspect a tarsal 
coalition. In addition to routine radiographs, several 
oblique views, as well as axial views, should be 
acquired to rule out a coalition at the sustentaculum 
tali. 

Treatment varies, depending on the severity of the 
symptoms. In most cases, conservative measures 
will alleviate the condition. Surgical intervention, in 
the form of an arthrodesing procedure, may be the 
treatment of choice for recalcitrant cases. 

It has been our experience that patients present- 
ing with this deformity cannot tolerate the rigors of 
recruit training and should be discharged from the 
service as they are identified. 

REFERENCES 

1. Anderson, cited by Bersani PA, Samilson RL: Massive 
familial tarsal synostosis. J. Bone Joint Surg (Am) 39A:1187- 
1190, 1957. 

2. Slomann, cited by Harris RI, Beath T: Etiology of peroneal 
spastic flat foot. J Bone Joint Surg (Br) 30B:624-634, 1948. 

3. Harris RI, Beath T: Etiology of peroneal spastic flat foot. J 
Bone Joint Surg (Br) 30B: 624-634, 1948. 

4. Vaughan WH, Segal G: Tarsal coalition with special refer- 
ence to roentgenographic interpretation. Radiology 60:855-863, 
1953. 

U.S. Navy Medicine 



BUMED SITREP 



RESIGNATION REQUESTS . . . Navy 

policy for voluntary resignation of 
regular and Reserve officers serving on 
active duty requires the following state- 
ments in the command's endorsement: 

• Comment on circumstances of all 
resignations, such comment to be made 
only after an interview has been held 
with the resigning officer. 

• For regular officers, a statement as to 
whether appointment in the Naval 
Reserve is recommended. 

When appropriate, an assessment 
should be provided of the need for a 
qualified relief, to include recommenda- 
tion concerning whether a billet can be 
left vacant and the maximum acceptable 
duration of such a vacancy. 

For more information, refer to SEC- 
NAV Instruction 1920.3H of 12 Aug 
1975. 

NEW DEVICES . . . The following phys- 
iology and water survival devices are in 
the design and procurement stage: 

• Multi-station disorientation demon- 
strator. 

• "Vertigon" type refresher training 
device for disorientation. 

• Universal helicopter underwater 
egress trainer (9D5). 

• Parachute drop and disentanglement 
trainer (9F6). 

These devices will be placed at Naval 
Aviation Schools Command in Pensa- 
cola, Fla., at certain aviation physiology 
units, and at other water survival train- 
ing agencies. 

ANTARCTICA STUDIES . . . Sixty Navy 

members who wintered over in Antarc- 
tica during Operation Deep Freeze 1976 
were among the subjects of a National 
Science Foundation research project 
that may end certain widespread beliefs 
about the relationship between pro- 
longed isolation and immunity from res- 
piratory diseases. 

Recently released findings of scien- 
tists who studied Navy men at Mc- 
Murdo Station and New Zealanders at 
Scott Station in Antarctica show that 
during prolonged isolation, resistance 
to disease did not decrease, contradict- 
ing previously accepted theory. 

If confirmed by further research, 
these findings will significantly advance 
knowledge of how long periods of isola- 
tion affect human physiological proc- 



esses. Study results may influence 
planning for programs which require 
long periods of isolation — further Arctic 
and Antarctic exploration and space 
travel, for example, 

KUDOS ... When asked recently for 
information about retention of USS 
Ranger crewmembers, the ship's com- 
manding officer identified medical sup- 
port from NRMC Bremerton as one very 
positive retention factor. Singled out for 
praise was the attitude of Bremerton 
medical personnel, as demonstrated by 
a genuine concern for Ranger crew- 
members and their families. 

ORGAN TRANSPLANTS . . . The Organ 
Transplant Service at the National 
Naval Medical Center has been trans- 
ferred to Walter Reed Army Medical 
Center, Washington, D.C. Merging the 
two military transplant programs should 
help reduce costs, provide a better 
training program for physicians and 
medical students, and ensure the best 
possible patient care. 

The agreement between the two med- 
ical centers calls for WRAMC to provide 
most direct patient care — to include 
preoperative dialysis and postoperative 



followup. NNMC and the Naval Medical 
Research Institute will continue to pro- 
vide the services of its tissue bank and 
oversee the work of technicians who de- 
termine tissue types of donated kidneys. 
Also, the Navy is responsible for pre- 
serving kidneys from the time they are 
obtained until they are transplanted. 

Both Navy and Army physicians will 
be able to carry out transplantation re- 
search, including animal experimenta- 
tion, at NMRI. 

Fellowships and residency rotations 
are available in clinical and investiga- 
tional areas of transplantation and 
organ preservation. 



ASBESTOS PROTECTION . . . Res 

pirators described as suitable for pro- 
tection against dusts and mists alone do 
not protect against dusts and mists that 
contain asbestos. Only equipment iden- 
tified in the National Institute of Occu- 
pational Safety and Health's list of ap- 
proved respirators as specifically ap- 
proved for use against asbestos-contain- 
ing dusts and mists is acceptable. Check 
NIOSH publication No. 77-195: Cumula- 
tive Supplement of NIOSH Certified 
Equipment, June 1977. 



PH2 Bob Weissleder 




NRDC SAN DIEGO . . . The Navy's largest, most modern dental facil- 
ity was dedicated 18 Nov 1977 at San Diego. The 132,000 square foot 
complex comprises three buildings: aclinic with 100 dental operating 
rooms; a supply and dental equipment repair facility; and the School 
of Dental Assisting and Technology, the Navy's only school for train- 
ing dental technicians. The new facility will serve fleet units in the 
San Diego area. !t will also be headquarters for Naval Regional Den- 
tal Center San Diego. 



Volume 69, April 1978 



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